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San Joaquin County <br /> Environmental Health Department DIRE <br /> '"•- gonna Heran.RENS <br /> x 600 East Main Suet <br /> '< Stockton,California 95202-3020 PROGRAMCE7GRf�/M�iTORS <br /> Robert Mcciellon,RENS <br /> Jeff Carruesco,REM%Rol <br /> Website.,www.sjgov.org/ehd Kasey Foley,RENS <br /> Phone: (209)458-3420 Linda Turkatle,REHS <br /> Pax: (209)464.0138 <br /> CLOSURE IN PLACE <br /> Business/Owner's Name: kA 1 SE R 6 R AA.4 N 6ri T r <br /> Facility Address: 't asaewfS AVE^0uE Af,41V-rjCCq <br /> Tank(s) Number: 1 <br /> Applicant'sName:SG,14Aj SwrFW Phone No125-5/g 7tV1 Date Submitted: /)-23-/O <br /> [ ] 1. Local County/City Fire District shall approve the Closure in Place(CIP)prior to Environmental Health <br /> Department(EHD)approval. UL6 A TPILOCO F.^4it- CoaR6SpoaoACwc jE <br /> [ ] 2. A registered geologist or qualified consultant shall submit/sign the CIP proposal. AV'A-_# .o <br /> [ ] 3. The applicant shall complete the"Application for Permit to Close Underground Storage Tanks Storing <br /> Hazardous Materials"form and remit a$366 review fee. Any additional review time required will be <br /> assessed at$122 per hour. <br /> [ ] 4. The applicant shall submit a technical work plan which includes the details of the proposed <br /> 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, <br /> any obstacle dictating boring locations, and any failed precision tests or unauthorized <br /> releases associated 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 <br /> collected) <br /> e) A description of sampling protocol and types of analyses to be performed. (If water is <br /> encountered, a water sample shall also be collected) <br /> f) 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 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 SJCEHD"and remit$122 boring permit fee. <br /> a) Inspection time is charge at$122 per hour. <br /> b) The above application shall be signed by the licensed drilling contractor or his authorized <br /> agent. (This authorization shall be submitted in writing.) <br /> C) A separate and complete "Application for permit SJCEHD" form and $122 permit fee is <br /> required for 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 aerial location of the <br /> closed UST, the hazardous substances it contained, and the closure method). <br /> [ ] 8. Approved by REHS: <br /> Date: <br /> EH 23 039 (Rev 8/03/10) <br />