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` 1 SQ N <�_� QAQ Environmental Health Department <br /> t COUNTY <br /> err : . . `� (arrril � rr-- ss grn , i » h - . rr. <br /> CLOSURE IN PLACE <br /> Business/Owner's Name: , f rh [ l T7l1 ` -e 7 A) + <br /> Facility Address: �i `�! 3 <br /> Tank(s) Number:/ � `° � ��� ` 71� Cj� 5J7` > 7 <br /> Applicant's Name: /d' j Phone #: 7L) l 74 ) •� NO Date Submitted: <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 /> t 3. The applicant shall complete the "Application for Permit to Close Underground Storage Tanks Storing Hazardous <br /> Materials" form and remit a $456 review fee. Any additional review time required will be assessed at $ 152 per hour. <br /> [- 4. The applicant shall submit a technical work plan which ipcludes 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 obstacle dictating <br /> boring locations, and any failed precision tests or unauthorized releases associated with the tanker '.. <br /> C) Cross-sectional drawing of tank and proposed angle borings. (Indicate where the borings will terminate) '.. <br /> d) A minimum of two borings and four soil samples per tank. (Indicate where samples will be collected) wj/ 1 ) > <br /> e) A description of sampling protocol and types of analyses to be performed. (If water is encountered, a water sample '.. <br /> / shall also be collected) It VLfl.z, <br /> f) Provide this office with the minimum detection limits that will be utilized in the suggested analysis. I� 5 <br /> 9) 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. The applicant shall complete the "Application for Permit SJCEHD". Submit a $456 Work plan fee and $152 per boring fee. <br /> a) Inspection time is charge at $152 per hour. <br /> b) The above application shall be signed by the licensed drilling contractor or his authorized agent. (This authorization <br /> shall be submitted in writing.) <br /> C) A separate and complete "Application for permit SJCEHD" form is required for each separate parcel. <br /> e) The drilling contractor performing work must have on file: <br /> i. A copy of the C-57 well driller's license. <br /> ii, A current copy of Worker's Compensation Insurance certificates <br /> iii. A completed "Contractor's Questionnaire". <br /> 6. The applicant shall complete the "Authorization to Release Analytical Information" form and obtain the signature of <br /> the property owner or his authorized representative. <br /> [pj ' 7. A notice to be placed on the deed of the property (describe exact vertical and aerial location of the closed UST, <br /> the hazardous substances it contained, and the closure method). <br /> p j <br /> [ ) 8. REHS Approval t'4, t f`u j (}. Date:. 0 <br /> RECEIVED <br /> OCT 2 8 2019 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <br /> 1868 E. Hazelton Avenue ( Stockton , California 95205 1 T 209 468-3420 F 209 464-0138 1 www.sjcehd. com <br />