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4�U±ty <br />San Joaquin County <br />'- Environmental Health Department <br />600 East Main Street <br />Stockton, California 95202-3029 <br />Website: www.sjgov.org/ehd <br />Phone: (209) 468-3420 <br />Fax: (209) 464-0138 <br />CLOSURE IN PLACE <br />Business/Owner's Name: Kaiser Permanente <br />Facility Address: 7373 West Lane, Stockton, CA, 95210 <br />Tank(s) Number: <br />none <br />Applicant's Name: Elite Four Contractors Phone #: 461-6337 <br />DIRECTOR <br />Donna Heran, REHS <br />PROGRAM COORDINATORS <br />Robert McClellon, REHS <br />Jeff Carruesco, REHS, RDI <br />Kasey Foley, REHS <br />Date Submitted: <br />[ ] 1. Applicant shall submit a written approval from the City or County Fire Prevention Bureau with jurisdiction <br />allowing the Closure in Place (CIP) prior to the Environmental Health Department (EHD) approval. <br />(] 2. A registered geologist or qualified consultant shall submit/sign 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 $375 review fee. Any additional review time required will be assessed <br />at $125 per hour. <br />[ ] 4. The applicant shall submit a technical work plan 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 <br />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 collected) <br />e) A description of sampling protocol and types of analyses to be performed. (If water is encountered, a <br />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 SJCEHD" and remit $125 boring permit fee. <br />a) Inspection time is charge at $125 per hour. <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 SJCEHD" form and $125 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 aerial location of the closed <br />UST, the hazardous substances it co ained, an he closure method). <br />[ ] 8. REHS Approval / Date: <br />EH 23 039 (Rev 8/01/11) i' <br />