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PUBLIC HPALTH SERVICES <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DIVISION <br />Karen Furst, M.D., M.P.H., Health Officer <br />304 East Weber Avenue, Third Floor • Stockton, CA 95202 <br />209/468-3420 <br />CLOSURE IN PLACE <br />Business/Owner's Name: '3an Jooqas <br />Facility Address: i$10 FQft 14-4 lion AvP-'j S4ock#00 CA lt2LE, <br />Tank(s) Number: Sweeps Number. Computer Number. <br />Applicant's Name: ''Scott EK Phone No: (IN) 960 8200 Date Submitted: <br />Local County/City Fire District shall approve the Closure in Place (CIP) prior to Environmental Health Division <br />(PHS/EHD) approval. <br />[ ] 2. A registered geologist or qualified consultant shall submit the CIP proposal. <br />[ ] 3. The applicant shall complete the "Application for Permit to CIose Underground Storage Tanks Storing Hazardous <br />Materials" form and remit a 5234 review fee. Any additional review time required will be assessed at S78 per <br />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 tank site: Previously and currently stored contents, tank capacity, tank location, any obstacle <br />dictating boring locations, and any failed precision tests or unauthorized releases associated with the tank. <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) <br />e) A description of sampling protocol and types of analyses to be performed. (If water is encountered, a water <br />sample shall also be collected) <br />f) Provide this office with the minimum detection limits that will be utilized in the suggested analysis. <br />�) 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 SJLHD" and remit S89 boring permit fee. <br />a) An initial fee of S89 includes the first hour of inspection time. If additional inspection time is required, a <br />S78 per haur fee will be assessed. <br />b) The above application shall be signed by the licensed drilling contractor or his authorized agent. (This <br />authorization shall be submitted in writing.) <br />C) A separate and complete "Application for permit SJLHD" form and S89 permit fee is required for each <br />separate parcel. <br />d) The drilling contractor performing work must have on file: <br />o 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 "Contractor's Questionnaire". <br />[ ) 6. The applicant shall complete the "Authorization to Release Analytical Information" form and obtain the signature <br />of the property owner or his authorized representative. <br />[ ] 7. A notice to be placed on the deed of the property (describe exact vertical and areal location of the closed UST, the <br />hazardous substances it contained, and the closure method). <br />[ ] 8. Approved by REHS: Date- <br />EH <br />ateEH _+ 039 (Rev 6110/94) <br />-\ Division of San Joaquin County Health Care Services <br />