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San Joaquin County <br /> Environmental Health Department DIRECTOR <br /> y, Donna Heran,REHS <br /> t 600 East Main Street <br /> Stockton, California 95202-3029 PROGRAM COORDINATORS <br /> Robert McClellon,REHS <br /> Ott _ <br /> Website: wwwsjgov.org/ehd +SCE ® <br /> Phone: (209)468-3420 <br /> Fax: (209)464-0138 OCT 10 201Z <br /> CLOSURE IN PLACE lNVIRONMENTALHEALTH <br /> Business/Owner's Name: St.JOseph'S Medical Center PERMIT/SERVICES <br /> Facility Address: 1800 North California Street, Stockton, CA, 95204 <br /> Tank(s) Number: NA <br /> Applicant's Name: Elite IV Contractors Phone#: 209-461-6816 Date Submitted: <br /> b(] 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 /> [X] 2. A registered geologist or qualified consultant shall submittsign the CIP proposal. <br /> [X] 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 /> ]K] 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 /> 0 A copy of the C-57 well driller's license. <br /> o A current copy of Workers Compensation Insurance certificate. <br /> o A completed"Contractor's Questionnaire". <br /> [X] 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 /> L>d 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 substa se it ai and the closure method). <br /> [ ] 8. REHS Approval Z Date: v Y <br /> EH 23 039(Rev 8/01/11) <br />