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C. <br />JoaquinSan <br />Environmental Health Department <br />.ii East Main Street <br />Stockton,i <br />Website: www.sjgov.orgiehd <br />Phone: (209) 468-3420 <br />Fax: (209) 464-0138 <br />DIRECTOR <br />Donna Heran, REHS <br />PROGRAM COORDINATORS <br />Robert McClellon, RENS <br />Jeff Carruesco, REHS, R01 <br />Kasey Foley, REHS <br />CLOSURE IN PLACECp/i'/sYG &A/AerA, gu/G®lk�, 45A4f1 <br />Business/Owner's Name: 4W FA+zn//4. 14A -I+e� L .Se;x)exL5 CO <br />Facility Address: 1602 LV-Ay";r& S? Jrvc/c>cl� �s7,ol <br />Tank(s) Number: 31- PSB 0 * 75' 39- 4s'2ta� G. <br />Applicant's Name:_ 4*%<) Phone #: 5!Q 636 MO Date Submitted: I. �! <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. V 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 />MP y®�r obstacle dictating boring locations, and any failed precision tests or unauthorized releases <br />V0AkA associated with the tank. <br />C) Cross-sectional drawing of tank and proposed angle borings. (Indicate where the borings will <br />S'1 s terminate) <br />PI,Pe-&/,/ c S 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. l 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 drillers license. <br />a A current copy of Worker's Compensation Insuranpe certificate. <br />o A completed "Contractors Questionnaire". <br />k -f 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. -dk I 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 contained, and the closure method). <br />(] 8. REHS Approval Date: <br />EH 23 039 (Rev 8/01/11) L ' �' l7hn A-FPLic�iv4 AA azaw .e is a /P <br />VA- IV7o A ,6altljI 4 �ou�14�7'�0� E7•r!L Y <br />