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0 0 <br />SANJOAQUIN RECEIVED Environmental Health Department <br />,--COUNTY-- <br />0 CT 10 2018 <br />GENERAL INFORMATION: ENVIRONMENTAL HEALTH <br />T <br />1, Obtain an EPA Site Number frorrAVQarmlinK Toxic Substances Control (800) 61 -TOXIC for <br />temporary hazardous waste removal activities associated with underground storage tank (UST) removals. <br />(411illill i I a I ILM i I Ill <br />5. Any changes in this document shall be approved by EHD prior to initiating work, <br />6. Closure -In -Place: If Closure -in -Place is the suggested method of abandonment, complete form EH 23 039 and <br />submit written approval from the local Fire Department. <br />60- <br />I- 11-Mili- a <br />8. The following documentation shall be submitted within 30 days of the tank removal date: <br />a) Analytical results, mailed directly from laboratory to EHD, including a chain of custody and quality <br />assurance and quality control (QA & QC). <br />b) LIST Tracking Record Sheet(s) and/or Tank Hazardous Waste Manifest(s). <br />C) Tank Closure Certification Form (DTSC: form 1249). <br />d) Hazardous Waste Manifests for piping, rinsate, residual fuel, or waste oil receipt. <br />a) Submit the backfill excavation certificate as required by San Joaquin County and the incorporated <br />City Building Departments. This report will be referred to the appropriate agency for their review. <br />subml for review. <br />IA the e%zAt atnmmia2t4-,% is lt�se"K ct4rmef ir susXendeef .2s 2 restl 2 Ie2kixjr UST systext It I -F -161e <br />prior to inating any assessment or remediation activities. To minimize delays, the work plan may be <br />2ubmItted concurrent with tank closure or installation plans. Address one copy of the work plan to the Site <br />Mitigation Unit for review. If the site is not currently in the Local Oversight Program, a billing form and a $456 <br />-ninimurn fee must be submitted with the Work plan. For further assistance contact the Site Mitigation Unit at <br />(20 9) 468-3420. <br />2 of 10 <br />