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i7priti VLIiWag <br />0 <br />• JOAQUIN COUNTY <br />1' • 1 f 1 � <br />Ernest M. Fujimoto, M.D., M.P.H., Acting Health Officer <br />445 N. San Joaquin Street ® P.O. Box 388 • Stockton, CA 95201-0388 <br />(209) 468-3420 <br />CLOSURE IN PLACE <br />Business/Owner's Name: <br />Facility Address: <br />Tank(s) Number: Sweeps Number: Computer Number: <br />Applicant's Name: Phone No: Date Submitted: <br />[ ] <br />I. Local County/City Fire District shall approve the Closure in Place (CIP) prior to Environmental Health <br />Division (PHS/EHD) approval. <br />[ ] 2. A registered geologist or qualified consultant shall submit the CIP proposal. <br />[ ] 3. The applicant shall complete the "Application for Permit to Close Underground Storage Tanks Storing <br />Hazardous Materials" form and remit a $234 review fee. Any additional review time required will be assessed <br />at $78 per hour. <br />(] 4. The applicant shall submit a technical workplan which includes the details of the proposed construction: <br />a) The reason for requesting a closure -in-place. <br />b) History of the tank site: Previously and currently stored contents, tank capacity, tank location, any <br />obstacle dictating boring locations, and any failed precision tests or unauthorized releases associated <br />with the tank. <br />c) Cross-sectional drawing of tank and proposed angle borings. (Indicate where the borings will <br />terminate) <br />d) A minimum of two borings and four soil samples per tank. (Indicate where samples will be collected) <br />e) A description of sampling protocol and types of analyses to be performed. (If water is encountered, <br />a water sample shall also be collected) <br />f) Provide this office with the minimum detection limits that will be utilized in the suggested analysis. <br />g) Obtain an EPA identification number for hazardous waste that is generated on site. <br />h) Provide a hazardous waste manifest for any hazardous waste that is generated on site. <br />i) Provide method for sealing the boring(s) and indicate sealing material to be utilized. <br />[ ] 5. The applicant shall complete the "Application for Permit SJLHD" and remit $89 boring permit fee. <br />a) An initial fee of $89 includes the first hour of inspection time. If additional inspection time is <br />required, a $78 per hour fee will be assessed. <br />b) The above application shall be signed by the licensed drilling contractor or his authorized agent. <br />(This authorization shall be submitted in writing.) <br />C) A separate and complete "Application for permit SJLHD" form and $89 permit fee is required for <br />each separate parcel. <br />d) The drilling contractor performing work must have on file: <br />o A copy of the C-57 well driller's license. <br />o A current copy of Worker's Compensation Insurance certificate. <br />o A completed "Contractor's Questionnaire". <br />[ ] 6. The applicant shall complete the "Authorization to Release Analytical Information" form and obtain the <br />signature of the property owner or his authorized representative. <br />(] 7. A notice to be placed on the deed of the property (describe exact vertical and areal location of the closed <br />UST, the hazardous substances it contained, and the closure method). <br />[ ] 8. Approved by REHS: <br />EH 23 039 (Rev 6/10/94) <br />Date: <br />A Division of San Joaquin County Health Care Services <br />