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San Joaquin Count • <br /> q Y <br /> ...........r Environmental Health Department DIRECTOR <br /> Donna Heran,RENS <br /> 600 East Main Street <br /> .< Stockton, California 95202-3029 PROGRAM COORDINATORS.: Robert McCletion,REHS <br /> Jeff Carruesco,RENS,RDI <br /> ` R <br /> Website:www sjgov.org/ehd Irtm <br /> Phone: (209)4+68-3420 <br /> VED <br /> Fax: (209)464.0138 <br /> NOV 2 4 2010 <br /> \ CLOSURE IN PLACE <br /> ENVIRONMENTAL HF_AL.TH <br /> Busines Owner's Name: KA i SE 2 E aAA,4N Eri T <br /> PERMIT/SERVICES <br /> FacilityA ess: 1111 as S AVEPjjtC A1,4 ?-60 <br /> Tank(s) Nu er: J. <br /> Applicant's Na :,"e_t4,y Strr'FW Phone No:12-S-3 5-1WI Date S miffed: /1-25-/0 <br /> [ ] 1. L cal County/City Fire District shall approve the Closure in Place IP)prior to Environmental Health <br /> De rtment(EHD)approval. SG.6 A 7rs►L000 E-"4i C0AX&S(po.vDAEwc E <br /> [ ] 2. A regist d geologist or qualified consultant shall submit/ i n the CIP proposal. ATA-#AD <br /> [ ] 3. The applican hall complete the"Application for Permit Close Underground Storage Tanks Storing <br /> Hazardous Ma rials"form and remit a$366 review f . Any additional review time required will be <br /> assessed at$12 er hour. <br /> [ ] 4. The applicant shall s mit a technical wo plan which includes the details of the proposed <br /> construction: <br /> ` ' a) The reason for req sting a closur -in-place. <br /> �-'�`'� b) History of the tank site. Previousl and currently stored contents,tank capacity,tank location, <br /> any obstacle dictating oring ocations, and any failed precision tests or unauthorized <br /> V releases associated with t ank. <br /> Cross-sectional drawing of a k and proposed angle borings.(Indicate where the borings will <br /> terminate) <br /> d) A minimum of two bori gs and fo soil samples per tank. (Indicate where samples will be <br /> collected) <br /> e) A description of s mpling protocol a types of analyses to be performed. (If water is <br /> encountered, a ater sample shall also a collected) <br /> f) Provide this o ice with the minimum det tion limits that will be utilized in the suggested <br /> analysis. <br /> g) Obtain an PA identification number for haza ous waste that is generated on site. <br /> h) Provide hazardous waste manifest for any hazardous waste that is generated on site. <br /> i) Provi method for sealing the boring(s)and indic to sealing material to be utilized. <br /> [ ] 5. The applic nt shall complete the"Application for Permit SJCEf{D"and remit$122 boring permit fee. <br /> a) spection 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 Iocatign of the <br /> closed UST, the hazardous substances it contained, and the closure method). <br /> [ ] 8. Approved by REHS: � �^ <br /> Date: l <br /> EH 23 039 (Rev 8/03/10) <br />