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PUBLIC HOALTH SERVICES SAN JOAQUIN COUNTY°a< ENVIRONMENTAL HEALTH DIVISION Karen Furst, M.D., M.P.H., Health Officer 304 East Weber Avenue, Third Floor • Stockton, CA 95202 "trFoR" 209/468-3420 Business/Owner's Facility Address: _ Tank(s) Number: _ Applicant's Name: Name: CLOSURE IN PLACE Sweeps Number. Phone No: Computer Number. Date Submitted: [ ] I. Local Counry/City Fire District shall approve the Closure in Place (CIP) prior to Environmental Health Division (PH&THD) approval. [ ] 2. A registered geologist or qualified consultant shall submit the CIP proposal. [ ] 3. The applicant shall complete the "Application for Permit to Close Underground Storage Tanks Storing Hazardous Materials" form and remit a 5234 review fee. Any additional review time required will be assessed at S73 per hour. 4. The applicant shall submit a technical workplan which includes the details of the proposed construction: a) The reason for requesting a closure -in -place - b) History of the tank site: Previously and currently stored contents, tank capacity, tank location, any obstacle dictating boring locations, and any failed precision tests or unauthorized releases associated with the tank. C) Cross-sectional drawing of tank and proposed angle borings. (Indicate where the borings will terminate) d) A minimum of two borings and four soil samples per tank (Indicate where samples will be collected) e) A description of sampling protocol and types of analyses to be performed. (If water is encountered a water sample shall also be collected) 0 Provide this office with the minimum detection limits that will be utilized in the suggested analysis. g) Obtain an EPA identification number for hazardous waste that is generated on site. h) Provide a hazardous waste manifest for any hazardous waste that is generated on site. i) Provide method for sealing the boring(s) and indicate sealing material to be utilized_ The applicant shall complete the "Application for Permit SILHD" and remit S89 boring permit fee. a) An initial fee of S89 includes the first hour of inspection time. If additional inspection time is required, a S73 per haur fee will be assessed. b) The above application shall be signed by the licensed drilling contractor or his authorized agent (This authorization shall be submitted in writing.) C) A separate and complete "Application for permit SILHD" form and S89 permit fee is required for each separate parcel. d) The drilling contractor performing work must have on file: o A coot' of the C-57 well driller's license. o A current copy of Worker's Compensation Insurance certificate. o A completed "Contractor's Questionnaire". 6. The applicant shall complete the "Authorization to Release Analytical Information" form and obtain the signature of the property owner or his authorized representative. A notice to be placed on the deed of the property (describe eeact vertical and areal location of the closed UST, the hazardous substances it contained, and the closure method). 8. Approved by REHS: EH :: 0.9 (Rev all 9 ) A Division or San Joaquin Countv Health Cate Services