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8-0d-1997 3:06PM FROM � <br /> PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL. HEALTH DIVISION <br /> Ernest M. Fujimoto, M.D., M.P.H., Acting Health Officer <br /> ceAoa <br /> 445 N. San Joaquin Street • P.O. Box 388 • Stockton, CA 95201-0388 <br /> (209) 468-3420 <br /> CLOSURE IN PLACE <br /> Business/Owner's Name- <br /> Facility <br /> ame Facility Address: ZSR L7DF'fl�e7 t 7®��T <br /> Tank(s) Number-. 0 <br /> Sweeps Number. Computer Number: <br /> Applicant's Name: Phone No.�XJ%IoZl Date Submitted: y7� <br /> I <br /> ( ] 1. Local County/City Fire District shall approve the Closure in Place (CIP) prior to EnvIironruental Health <br /> Division (PHS/EHD) approval <br /> I <br /> ( ] y A registered geologist or qualified consultant shall submit 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 5734 review fee. Any additional review time required will be assessed <br /> at $78 per hour. <br /> ( ] 4. The applicant shall submit a technical workplan which includes the details of the proposed construction: <br /> a) The reason for requesting a closure•in-place. <br /> b) History of the rant site: Previously and currently stored contents, tank capacity, tank location, any <br /> obstacle dictating boring locations,and any failed precision tears or unauthorized releases associated <br /> with the tank. <br /> C) Cross-sectional drawing of rank and proposed angle borings. (Indicate where the borings will <br /> terminate) <br /> d) A minimum of two boring and four soil samples per tank. (Indicate where samples will be collected) <br /> e) A description or sampling protocol and types of analyses to be performed_ (Ir water is encountered, <br /> a water sample shall also be collected) <br /> Provide this office with Elie 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 sealinz the boring(s) and indicate sealing material to be utilized. <br /> ( ] 5. The applicant shall complete the 'Application for Permit STLHD" and remit S89 boring permit fee. <br /> a) An initial fee of 589 includes the first hour of inspection time. If additional inspection time is <br /> required, a S78 per hour fee will be assessed. <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 permir STLHD" form and S89 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 Worker's Compensation Insurance certificate. <br /> o A completed "Connector'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 an the deed of the property (describe exact vertical and areal location of the closed <br /> UST. the hazardous substances it contained, and the closure method). <br /> ( ] 8. Approved by REAS- Dare. <br /> EH 23 039 (Rev 6/10/94) <br /> A Divivion of S.n Jwquin Gwmey He+lth Con Srrvicex <br />