Laserfiche WebLink
PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY Q� <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Karen Furst, M.D., M.P.H., Health Officer •. <br /> 304 East Weber Avenue,Third Floor • Stockton, CA 95202 <br /> 209/468-3420 <br /> CLOSURE IN PLACE <br /> Business/Owner's Name: \ T��- / Ra. <br /> Facility Address: S roe,h:&.-, CA <br /> Tank(s)Number: _ Sweeps Number: Computer Number: Applicant's <br /> Niae:L�i��, f w. Sc r��.P Phone No:zc j -1G-Llsr Date Submitted: <br /> 1. Local County/City Fire District shall approve the Closure in Place(CIP)prior to Environmental Health Division <br /> (PHS/EHD) approval. <br /> :k 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 5267 review fee. Any additional review time required will be assessed <br /> at 589 per hour. <br /> [ j 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 %vimere -he bonn,s 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 zncOLIntCred, <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 .itilized. <br /> [ ] The applicant shall complete the "Application for Permit SJI.HD" and renrit S89 boring permit fee. <br /> a 1 An initial fee of S89 includes the first lour of inspection time. If additional inspection rime c ri?Qu ,�d, <br /> a 589 per hour fee will be assessed. <br /> b) The above application shall be signed by the licensed drilling contractor or his authorized agent. (i is <br /> authorization shall be submitted in writing.) <br /> c) A separate and complete"Application for permit SJLHD" form and S89 permit fee is required for each <br /> 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 /> b. 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 /> ( ' A notice to be placed on the deed of the properryy(describe exact vertical and areal location of:he closed i.iSi. <br /> the hazardous substances it contained, and the closure method). <br /> ] S. 4pproveci b RE S <br /> Date: 2 D <br /> aH:1 aSv :Rcv.+.,.uiI iv•ulon of San oaquin Wunty Hralth Care SCfVICr.S <br />