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PUBtIC HEALTH S?tVICES <br />SAN JOAQUIN COUNTY <br />JOGI KHANNA M.D., M.P.H. <br />Health Officer <br />P.O. Box 2009 • (1601 East Hazelton Avenue) • Stockton, California 95201 <br />(209)468-3400 <br />CLOSURE IN PLACE POLICY <br />Closure -In -Place (CIP) applicant shall submit the following information. <br />[vf 1. Local County/City Fire District shall approve the CIP prior to PHS/EHD approval. �f////f'6 <br />[ �]� 2. A registered geologist or qualified consultant shall submit the CIP proposal. <br />[✓rte 3. Complete the "Application - Environmental Health Permit/Services" form and remit a $35 workplan review fee. <br />o Additional review time required will be assessed at $35 per hour. <br />[✓]� 4. A technical workplan shall include a typical drawing and details of proposed construction: <br />-alr' The reason for requesting a closure -in-place. <br />,bj' History of the tank site: Previously and currently stored contents, tank capacity, tank location, anv obstacle <br />dictating boring locations, and indicate if their are any failed precision tests or unauthorized releases <br />associated with the tank. <br />1-r_/ Cross-sectional drawing of tank and proposed angle borings. (Indicate where the borings will terminate) <br />A minimum of two borings and four soil samples per tank. (Indicate where samples will be collected) <br />A description of sampling protocol and types of analyses to be performed. (If water is encountered a <br />C water sample shall also be collected) <br />�t Applicant shall provide this office with the minimum detection limits that will be utilized in the suggested <br />analysis. <br />g) Obtain an EPA identification number for hazardous waste that is generated at the site. <br />Provide a hazardous waste manifest for any hazardous waste that is generated on site. <br />5. Complete the "Application for Permit SJLHD" and remit $35 boring permit fee. <br />An initial fee of $35 includes the first hour of inspection time. If additional inspection time is required, <br />a $35 per hour fee will be assessed. <br />The above application shall be signed by the licensed drilling contractor or his authorized agent. This <br />authorization shall be submitted in writing. <br />_x,� A separate and complete "Application for permit SJLHD" form and $35 permit fee is required for each <br />differing street address. <br />The contractor performing work must have: <br />_-o— A copy of the C-57 well driller's license on file. <br />,-e—" A current copy of Worker's Compensation Insurance certificate on file. <br />A completed "Contractor's Questionnaire" on file. <br />[VK 6. Complete the "Authorization to Release Analytical Information" form and ensure the signature of property owner <br />his authorized representative. <br />A Division of San Joaquin County Health Care Services 0 <br />