Prepared - sjgov.org...Storage Tank Abatement San Joaquin County Human Services Agency Stockton,...

Underground Storage Tank Abatement Scope of Work

SAN JOAQUIN COUNTY HUMAN SERVICES AGENCY

Prepared for:

San Joaquin County Capital Projects Courthouse

222 East Weber Avenue, Room 678 Stockton, California 95202

Prepared by:

WESTON SOLUTIONS, INC. 428 Thirteenth Street

64 Floor, Suite B Oakland, California 94612

WESTON Project No. 03733-021-003

January 2010

Underground Storage Tank Abatement San Joaquin Coun_ty Human Services Agency Stockton, California

TABLE OF CONTENTS

1.0 1.1 1.2 1.3

2.0 2.1 2.2

3.0 4.0

INTRODUCTION 1 Location and Description 1 Operational History 1 Previous Work 2

Underground Storage Tank Abatement 5 Permitting/Notifications 5 Work Plan/HASP 6

2.3 Tank Abatement 6 2.3.1 UST Removal Option 7 2.3.2 UST Closure In Place Option 8

2.4 Confirmation Soil Sampling 8

2.5 Site Restoration 9 Report 11 Miscellaneous 12

List of Figures

Figure 2-1 Site Location Map 4

Figure 2-2 Site Layout Map 10

List of Appendices

Appendix A

Appendix B

Appendix C

Appendix D

Appendix E

Site Photographs

City of Stockton Encroachment Permit

San Joaquin County EHD Application for Permit To Close Underground Storage Tanks Storing Hazardous Materials

San Joaquin County EHD Application for Closure In Place Application

City of Stockton Fire Department One Time Fire Inspection Permit Application

Underground Storage Tank Abatement San Joaquin County Human Services Agency Stockton, California

LIST OF ABBREVIATIONS AND ACRONYMS

•tg/L bgs BTEX

EHD

EPA

HSA

LEL

mg/kg MSL

QA/QC TPH-d

TPH-g USTs

VOC

WESTON

micrograms per liter

below ground surface

Benzene, Toluene, Ethylbeneze, total Xylenes San Joaquin County Public Health Environmental Health Division,

United States Environmental Protection Agency San Joaquin County Human Services Agency lower explosive limit

milligrams per kilogram

mean sea level

quality assurance/quality control

total petroleum hydrocarbons as diesel

total petroleum hydrocarbons as gasoline underground storage tanks

volatile organic compound Weston Solutions, Inc

ii


1.0 INTRODUCTION

The San Joaquin County Capital Projects Division has tasked Weston Solutions, Inc. (WESTON ®) to develop a scope of work for the abatement of underground storage tanks (USTs) located at the San Joaquin County Human Services Agency (HSA) building. The HSA building was constructed at the site of a former gasoline service station (site) which utilized USTs that released petroleum hydrocarbons to subsurface soil and groundwater. A

new UST was discovered at the HSA building while attempting to drill a groundwater monitoring well in July 2008. The San Joaquin County Public Heath Services Environmental Health Division (EHD). issued a Notice to Abate Immediately requiring the USTs to be removed or closed in place. This scope of work describes the details and particulars for the UST abatement needed for the Capital Projects Division to procure a tank removal contractor.

Contractors shall submit or have on file with the EHD information verifying that they possess a current State Contractor's License (A, B, C-36, C-61/D-40), State Hazardous Substance Removal Certificate, Workmen's Compensation Insurance, and a City of Stockton business license. A site walk will not be scheduled; however, the site is a public sidewalk and can be visited at any time.

1.1 Location and Description

The HSA building occupies the majority of the city block bounded by Market, East Washington, San Joaquin and South Sutter Streets in downtown Stockton, California. The Site address is 145 South Sutter Street. A former gasoline service station was located at the

comer of East Washington and South Sutter Streets. The UST site is bounded to the west and north by the HSA building, to the south by East Washington Street, and to the east by South Sutter Street (Figure 1-1).

1.2 Operational History

In April and May 1988, the following USTs were removed from the site:

• Two 10,000 gallon unleaded gasoline USTs • One 5,000 gallon super unleaded gasoline UST • One 500 gallon used oil UST

• Three 800 gallon sand filled USTs (unknown use).

Additionally, two 550 gallon leaded gasoline USTs and one 500 gallon fuel oil UST were

removed from the HSA building site away from the former gasoline service station. Details of the gasoline service station history or prior use of the land is not available. Following the removal of the USTs, the HSA building was constructed during the late 1980s and early 1990s.


1.3 Previous Work

In 1988, an investigation was conducted to assess the extent of petroleum hydrocarbons in soil and groundwater and three groundwater monitoring (MW-1, MW-2, and MW-3) were

installed. Petroleum hydrocarbons were detected in soil samples collected from beneath the

some of the tanks.

In 1989, petroleum hydrocarbon contaminated soil in the area of the former gasoline service station was excavated and disposed of off site. Approximately 2,000 cubic yards of contaminated soil was excavated to groundwater (approximately 27 to 30 feet below ground surface (bgs)). Soil samples taken from the southwest portion of the excavation indicated that

a limited volume of soil in excess of the target cleanup level remained but could not be removed because of site constraints. The excavation was backfilled and compacted with imported clean soil.

In 1991, five additional wells (MW-4 through MW-8) at locations upgradient and downgradient from the Site. Groundwater monitoring well MW-1 was previously abandoned in preparation of construction of the HSA building.

In 1995, groundwater monitoring wells MW-2A and MW-3A were installed to replace wells MW-2 and MW-3 which went dry due to a drop in the regional groundwater table. In addition to installing the deeper wells, monitoring well MW-3 was abandoned.

In 1996, groundwater monitoring well MW-9 was installed in the parking lot across East Washington Street and south of the former USTs to assess groundwater conditions upgradient of well MW-2A. A groundwater monitoring program has been in place at the site from 1989 to present.

In June 2008, an investigation was conducted to asses the vertical extent of soil and groundwater contamination at the site at the request of the EHD. While attempting to install a

deep groundwater monitoring well in the sidewalk along South Sutter Street, a UST was

found with an air knife and vacuum track while cleating the well location for possible underground utilities.

In July 2008, a geophysical survey was conducted along the sidewalk from the comer of East Washington and South Sutter Streets to the location of the former USTs north of the former service station. The geophysical survey identified five electromagnetic anomalies and one

ground penetrating radar anomaly along the sidewalk. One of anomalies was aligned with the newly discovered UST, however interference from rebar and wire mesh in the sidewalk limited the effectiveness of the survey.

The geophysical survey anomalies were investigated by excavating the areas using an air knife and vacuum truck after coring through the sidewalk. Five 10-inch diameter borings were excavated to 10 feet bgs. One additional UST was identified south of the UST discovered in July. Soil observed at the other boring locations appeared to be undisturbed native soil.

Underground Storage Tank Abatement San Joaquin Coun_• Human Services Agent_ Stockton, Cal(fornia

In January 2010, the newly discovered USTs were further investigated by excavating the

areas using an air knife and vacuum truck to assess the quantity, dimensions, and locations of the USTs. Eight 10-inch diameter borings were excavated to 8 feet bgs. One additional UST

was identified north of the UST discovered in July 2008. Soil observed at the southern most boring location appeared to be undisturbed native soil. The lengths of the northern USTs

were determined to be approximately 10 feet and are located 2 to 3 feet from the curb. The width of the southern UST is approximately 3 feet. A 4-inch diameter cast iron sewer pipe was identified north of the USTs. The distribution of the USTs indicate one additional UST

may be located north of the southem UST encountered in borings M-1 and T-8. The fiber optic line was not encountered in any of the borings.

Underground Storage Tank Abatement San Joaquin Coun_tv Human Services Agency Stockton, California

Site location

4

Underground Storage Tank Abatement San Joaquin Count_ Human Services Agency Stockton, California

2.0 Underground Storage Tank Abatement

Three USTs have been identified beneath the sidewalk between the HSA building and South SuRer Street. Based on the USTs orientation and results of the geophysical and air knife borings, one additional tank may be located at the site. The identified USTs are located five feet beneath the sidewalk and are aligned perpendicular to the street. The diameters of the USTs are estimated to be approximately 3 to 4 feet and approximately 10 feet long. For estimating purposes, assume the USTs have a capacity ranging from 500 to 1,000 gallons and

are constructed of single wall steel. A fiber optic line operated by Verizon/MCI is located approximately 2 to 3 feet beneath the sidewalk and 2 feet above the USTs. The contents of the UST are unknown and are expected to be fuel related to the previous use of the site as a

gasoline service station. Unusually high concentrations of benzene have been historically detected in well MW-2 located near the USTs. The source of the benzene groundwater contamination may be the newly discovered USTs. A Site Layout Map is presented as Figure 2-1; photographs showing the UST area are included in Appendix A.

The UST abatement must be completed in accordance to the EHD, city, state, and federal regulations and general industry practices. This scope of work includes pertinent information required to properly abatement the USTs and provide a basis to determine a cost estimate; however, it may not outline all regulatory agency requirements.

2.1 Permitting/Notifications

An encroachment permit (Revocable Permit No. 08-06W) with the City of Stockton Public Works Department (City) was obtained by Capital Projects Division for the well installation and will cover UST abatement activities (Appendix B). The contractor will be responsible for the coordination of appropriate City inspections prior to site activities and at the completion of the work. The contractor will conform to the provisions in the permit and provide evidence of insurance naming the City as additionally insured.

An Application for Permit to Close Underground Storage Tanks Storing Hazardous Materials and a Closure in Place Application must be completed and approved by the EHD (Appendix C). Written approval for closure in place from the local fire department must be submitted with the Closure in Place. Tank Closure permit will be obtained by the contractor from the EHD (Appendix D); however, Capital Projects will be responsible for fees associated with the permit.

Complete the Authorization to Release form signed and dated by a HSA representative.

Obtain an EPA Site Number from the Department of Toxic Substances Control for temporary hazardous waste removal activities associated with underground storage tank removals.

A permit from the Stockton Fire Department will need to be obtained along with a written approval for a closure in place (Appendix E).


Underground Service Alert (USA) will be notified by the contractor after the work area is outlined in white paint. Coordination with Verizon/MCI will be necessary to ensure the fiber optic utility is properly located and protected by work activities.

Submit a "Service Request" form with the appropriate fees, submit completed UPC forms for Facility and Tanks (formerly State A & B forms) and complete the "Underground Storage Tank Program Fee Worksheet".

Obtain a boring permit for the collection of soil samples beneath UST if the closure in place option is exercised.

A traffic control plan following Manual of Traffic Control Devices may be required for the work if traffic lanes are reduce to less then 10 feet. Pedestrian control and sidewalk closures will need to be implemented.

The contractor will need to coordinate with the HSA facility manager for the work.

The Contractor will need to coordinate with Verizon/MCI OSP Construction Manager for temporarily moving the fiber optic line.

2.2 Work Plan/HASP

A work plan detailing the tank removal or closure in place procedures will need to be prepared by the contractor and submitted to the EHD for approval prior to work. The work plan will detail removal procedures, sampling and analyses procedures and backfilling specifications and site restoration. Cal/OSHA requires that a Site-Specific Health and Safety Plan (HASP) be maintained on site during closure activities. The HASP will need to be submitted to the EHD with the work plan and permit application

2.3 Tank Abatement

Ideally, the USTs should be removed and contaminated soil beneath the USTs should be excavated to the furthest extent as possible. However, the UST's proximity to the street, building and fiber optic line will limit the size of the excavation. If the USTs are removed and contaminated soil is to be excavated, then the work shall be conducted on a weekend due to the potential of high concentrations of benzene, documented in groundwater samples collected from MW-2, which could potentially cause exposure to county workers and the public. The City of Stockton limits work hours from 7:00 AM to 10:00 PM.

Prior to the UST removal, the work area will need to be secured with fencing and posting of "no smoking" signs. The sidewalk will be closed and pedestrian detours should be implemented with use of appropriate signage. Curb space along South Sutter Street is marked

as a loading zone and no parking zone, however no parking signs should be posted in the loading zone to prevent county or other vehicles from occupying the space.

Underground Storage Tank Abatement San Joaquin Coun _tv Human Services Agency- Stockton, California

The sidewalk above the tank area should be saw cut and removed and the first few feet of material will need to be carefully excavated by hand to expose the fiber optic line located approximately two feet bgs. The fiber optic line is in use and can not be removed. A Verizon/MCI utility contractor may be able to temporarily move the utility a few feet dependent on the amount of cable slack in that area. The excavation should be continued to

expose the top of the USTs to expose vent and fill ports/piping and determine the length and location of the USTs and whether the removal of the tanks is possible without jeopardizing the integrity of the fiber optic line, street and building. The trees along the sidewalk will not require removal or replacement.

2.3.1 UST Removal Option

If the USTs are oriented in a manner that is conducive for their removal based upon exposing the USTs and fiber optic line, they will need to be prepared for safe removal. The USTs will be opened at a fill or vent pipe and their contents will be inspected. If the USTs are

discovered to be filled with sand or other backfill material, they should still be removed to allow the removal of potentially contaminated soil. If the tanks are not backfilled, any free liquids will need to be removed from the USTs and rinsed with water to remove residual liquids. The liquids are to be pumped using an intrinsically safe method into a vacuum truck and transported under Hazardous Waste Manifest by a state registered hazardous waste hauler to a proper disposal facility. For estimating purposes, assume 200 gallons of liquid/sludge will be in each UST.

The USTs, previously containing flammable/combustible materials, shall be made safe for removal by inserting at least 22.2 pounds of dry ice (carbon dioxide) per 1,000 gallons tank capacity to sufficiently achieve an atmosphere of less than 10% oxygen and less than 20% lower explosive limit (LEL) in the UST. The LEL and oxygen percentage will be measured with a combustible/flammable gas detector to ensure that the UST does not contain an

explosive environment.

The UST will be carefully removed from beneath the fiber optic line and from the excavation where it will be inspected for corrosion and holes. Dirt should be removed from outside of the UST and vents and fill ports in the UST must be plugged with vented plugs prior to transportation.

The EHD's UST Tracking Record shall accompany each tank removed from site. Tank(s) will be issued an identification number which EHD's representative will note on the UST Tracking Record. The contractor will affix same identification number onto tank end using fluorescent spray paint. The UST and piping are to be transported under Hazardous Waste Manifest by a state registered hazardous waste hauler to a proper disposal facility.

Contaminated soil from beneath the USTs will need to be excavated to furthest extent as

possible with limited shoring to protect the street. Shoring will need to be installed in a

manner that will not damage the fiber optic line or the groundwater monitoring well. Due to limited space at the site, soil will need to be excavated and direct loaded for transport offsite for waste profiling and disposal. For estimating purposes, assume an estimated 100 yards of

7

Underground Storage Tank Abatement San Joaquin Coun _ty Human Services Agency Stockton, California

soil will require disposal at a proper landfill. Approximately 60 yards of soil from above the UST should not be contaminated and may be reused if suitable for compaction. This soil may be able to be temporarily stored in roll off bins pending reuse. The contractor will be responsible for sampling and laboratory analyses required for properly profiling the soil for disposal. The soil should be assumed to be contaminated with leaded gasoline and diesel fuel.

2.3.2 UST Closure In Place Option

If the USTs are oriented in manner where removal efforts would be deleterious to the fiber optic line, building, street, or other utilities, the USTs may warrant closure in place. Although this option is not preferred as potentially contaminated soil would remain in the subsurface, it

may be the best option due to the limited access and difficult shoring design due to the fiber optic utility.

The USTs will be opened at a fill or vent pipe and their contents will be inspected. If the USTs are discovered to be filled with sand or other appropriate backfill material, they may be deemed by the EHD as adequately abandoned. If the USTs have been determined to have been previously abandoned, then any free liquids will need to be removed from the USTs and triple rinsed with water to remove residual liquids. The liquids are to be pumped using an

intrinsically safe method into a vacuum truck and transported under Hazardous Waste Manifest by a state registered hazardous waste hauler to a proper disposal facility. The USTs will then be filled with a cement slurry or other approved backfilled material to prevent the potential collapse of the tanks and surface settlement.

2.4 Confirmation Soil Sampling

Soil samples will need to be collected from the UST excavation or from beneath the USTs with angled borings if closed in place. The contents of the USTs are unknown and will require the following analytical testing:

• TPH-gasoline by EPA Method 8015

• TPH-diesel by EPA Method 8015

• VOCs including fuel oxygenates and additives by EPA method 8260

• LUFT metals (cadmium, chromium, lead, zinc and nickel) by EPA Method 8260

• PCBsby EPA Method 8010

If pentachlorophenol is identified, analyze the soil and/or water sample for dioxins and furans by EPA Method 8290 and pesticides by EPA Method 8081A.

If the USTs are removed, then at least two soil samples will need to be collected from 1 to 2 feet beneath each UST. Excavation confirmation samples will need to be collected from each sidewall at the completion of excavating activities. An estimated 14 soil samples will be required.


If the USTs are closed in place, then two angled borings drilled with direct push techniques will need to be drilled to collect soil samples from beneath the tanks after they have been properly closed in place. An estimated 8 borings and 8 soil samples will be required.

Soil samples will be contained in appropriate containers. Samples for VOC analyses will be contained in Encore samplers or equivalent sampling containers. The samples must be submitted to the laboratory under chain of custody control and placed in an ice chest and chilled to 4 ° + 2 ° Celsius along with a temperature blank. Analyses of the samples must be a

3 rd party contracted laboratory licensed in the state of California for the requested analyses.

Groundwater at the site is 25 to 30 feet bgs and is not expected to be encountered in the UST excavation. An excavation water sample is not anticipated for this site.

2.5 Site Restoration

Once the USTs have been removed or abandoned in place, the excavations will need to be backfilled with suitable material. The City of Stockton will inspect the backfilling procedures and will require compaction testing. The excavation will be backfilled with clean fill and compacted to 90% for each 12-inch lift. The final lift will require 95% compaction followed by 4-inches of compacted asphalt base rock and 6-inches of 6-sack +/- ¾ concrete. The sidewalk will need to be saw cut to the tile seams and restored to match the existing surface.

9

Underground Storage Tank Abatement San Joaquin Coun _ty Human Services Agenqv Stockton, California

Site Layout

10

Explanation • Underground Storage Tank (UST)

(,'•-• Potential UST Location

• Previous Air Knife Boring

•1( January 2010 Air Knife Boring

Groundwater Monitoring Well

Human Services Agency

Building

(•) Sidewalk Bollard

,/ Tree

Utility Vauit (Street Lights)

• Utility Vault (Reserved for Traffic Signals)

Fiber Optic Line

Electrical Line f"•Sewer (Abandoned?)

MW-2

East Washington Street

T-• T-2

:M-1

!l

.-=

Additional UST Investigation Borings San Joaquin County Human ,Services Agency Building

145 South Sutter Street Stockton, California

Figure

Underground Storage Tank Abatement San Joaquin County Human Services Agency Stockton. California

3.0 Report

A brief report will be prepared by the contractor documenting the UST abatement procedures and analytical results of the soil samples collected from beneath the USTs. The report should included copies of permits, manifests, laboratory analytical results, figures showing soil sampling locations and photographs.

The EHD will require the following to be submitted within 30 days of the UST abatement:

• Analytical results, mailed directly from laboratory to EHD, including a chain of custody and quality assurance and quality control (QA & QC).

• UST Tracking Record Sheet(s) and/or Tank Hazardous Waste Manifest(s). • Tank Closure Certification Form (DTSC form 1249). • Hazardous Waste Manifests for piping, rinsate, residual fuel, or waste oil receipt and

soil.

• Submit the backfill excavation certificate as required by San Joaquin County and the incorporated City Building Departments.

11


4.0 Miscellaneous

The subcontractor will, at their own time and expense, procure all licenses and certificates that may be required by law for the execution of the prescribed site work. The subcontractor will comply with all federal, state and local laws, ordinances, rules and regulations relating to the performance of the work as defined in these bid specifications.

At the completion of field operations it will be the responsibility of the subcontractor to

restore the site as nearly as possible to its original condition.

The contract bid items will include all services, labor equipment, transportation, material, and supplies needed to complete the work and not supplied by the County. Payment for these specified items will be provided based on the Counties approval of the daily report. Down time incurred by the subcontractor will not be approved for payment by County.

No other payments for unspecified work will be made.

The County will evaluate the bid proposals. The review will be based on the responsiveness to bid requirements, the bidders experience, technical capabilities, compliance with OSHA regulations, availability and cost.

The subcontractor will comply with all Occupational Safety and Health Administration (OSHA) regulations regarding the use of personal protective gear on hazardous waste sites. The subcontractor is required under 29 CFR 1910.120 to develop their own site-specific health and safety plan. This plan shall be submitted to the County for review at least two days prior to the start of work. Expendable protective equipment will be included as part of the sampling task. Work will be performed in Level D type protective clothing unless site condition warrant Level C personal protection.

12

APPENDIX A

Appendix A Newly Discovered USTs Photographs

San Joaquin County Human Services Agency Stockton, California

UST Area Viewed From Sutter Street

Human Services Agency Building Viewed From Sutter and Washington Streets

Appendix A Newly Discovered USTs Photographs

San Joaquin County Human Services Agency Stockton, California

Steel UST Observed in AirVac Boring

View of UST Area and Fiber optic Line Location AirVac Boring Encountering UST is Located at Circular Concrete Patch

APPENDIX B

Applicant's Nam(l•l•L•l••

L0catlon of Proposed Work, etc.

CITY OF STOCKTON PUBLIC WORKS DEPARTMENT

7 1 0 9 8 APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY

Owner/Contractor Address Estimated Starting Date /V•O,'•, '•1•" Completion Dat e "d•ul,•_

APPROVED: BY THE PUBLIC WORKS DIRECTOR

Subject to the GeneralProviSions and Special Conditions, and all work must conform to the pr(•ject's approved .Storm Water Pollution Prevention Plan or the most current vemion of the City of Stockton Storm Water Pollutlon Prevention Malnt•)•ce Staff Guide, whlche•er is applicable. )

•O•-'• Permit Expiration Date

(or We) hereby apply.for an Encroachment Permit to carry out the following work:

" T '..-, ATTENTION: Appl.icant/Contraetor- you are responsible to replace all bi'oken, damaged, and/or raised sidewalk, curb and gutter from score mark to score mark adjacent to the parcel; -remove USA markings upon completion of the permitted work.

The above named apldle.•l•t hereby requezt• permission to

Additional Footage Fee

Sewer Tap Deposit

/') TOTAL DEPOSIT

Improvement Plan No.

Supplemental Conditions:

PERMIT NOT'VAUD WITHOUT A CONTROL NUMBER, CALL (209) 937-8386 TO REQUEST A CONTROL NUMBER NO LESS "rH•24 HOURS, BUT NOT IN EXCESS 0F72 HOURS PRIOR TO START OF WORK, CONTROL#,

Sho• •ketch above or refer to drawing e•bmltted

IMPORTANT: Applicant hereby agrees (0 comply W.ith all provisionsof thisperm]t, a• well •S ail_applibable City ordinances, resol, utions, Standards arid Spebiflcations currently In effect, and to pay to the City its actual Cost for removal and p•'oper replaoetner•t of any item which does not meet the above requirements. Failure to. comply will be cause for revocatioh of this permit. Applicant agrees to Indemnify and hold the City harmless.aga!nst any: and all Io•sses, cos.•s, or •.am•g.es r .esultlng from Injury to.persons, death of person or damage to property occurring at the Site OT, or. as a resultoT, work to oe-penormeo unoer this permit.A certificate of Insurance shall be subrnitled to the City Risk Managi)r prior to issuance of this permit.

IF THE WORK DOES NOT-COMMENCE WITHIN 72.HouRS OF THE ISSUANCE OF A CONTROL NUMBER, THE CONTROL NUMBER WILL BECOME INVALID AND THE PERMITI'EE SHALL CALL FOR ANEW CONTROL NUMBER. (FORCAPffAL IMPROVEMENT PROJECTS OR SUBDNISlON IMPROVEMENTS, PERMn-rEE SHALL CONTACT THE ASSIGNED CITY PROJECT ENGINEER AT (209) 937-8411 FOR SPECIFIC INSTRUCTIONS PRIORTO THE BEGINNING OF ANY WORK,) PRIOR TO ANY REQUIRED INSPECTIONS, AS IDENTIFIED ON THE REVERSE SIDE OF THIS PERMIT, PERMITI'EE SHALL CALL (209) 937-8381.

READ GENERAL PROVISIONS ON THE REVERSESIDE OF THIS PERMIT BEFORE SIGNING•

'" 1" -Permittee (white) 2 "d -Inspection (pink) 3 ra -File (yellow) 4 m -Finance (whlte)

CITY OF STOCK. TON

Well Location:

Permittee:

REVOCABLE PERMIT

ONE GROUND WATER MONITORING WELL INSTALLED BEHIND FACE OF CURB

145 SOUTH SUTTER STREET

SAN JOAQUIN COUNTY

222 EAST WEBER AVENUEI ROOM 678

STOCKTON! CA 95209

Permit No.: 08-06W Date: May 9, 2008

In accordance with Ordinance 028-00, passed by the Council of the City of Stockton on

November 6, 2000, a permit revocable at the pleasure of the Public Works Director of the City of Stockton is hereby granted to:

SAN JOA•UIN COUNTY

To install and maintain one (1) ground water monitoring well (MW-10) in the vicinity of 145 South Sutter Street, Stockton CA.

This permit is granted under the following terms and condRions:

This revocable permit is granted subject to the Standard Conditions Applicable to Revocable Permits adopted by this City Council by Resolution No. 00-0554 on

November 14, 2000, and on file in the Office of the City Clerk of the City of Stockton.

The general location of the weil shall be as shown on the map attached. The preCise location shall be determined in the field by the City of Stockton. The well shall not be installed within any travel lanes.

APPENDIX C

ENVIRONMENTAL HEALTH DEPARTMENT

Donna K. Heran, R.E.H.S. Director

Laurie A. Cotulla, R.E.H.S. Assistant Director

SAN JOAQUIN COUNTY 600 East Main Street

Stockton, California 95202 Telephone: (209) 468-3420

Fax: (209) 468-3433

Unit Program Coordinators Carl Borgman, R.E.H.S.

Mike Huggins, R.E.H.S., R.D.I. Margaret Lagorio, R.E.H.S. Robert McClellon, R.E.H.S. Jeff Carruesco, R.E.H.S. Kasey Foley, R.E.H.S.

APPLICATION FOR PERMIT TO CLOSE UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS

GENERAL INSTRUCTIONS:

[] 1. Submit all information in triplicate. Answer all questions, leaving no blanks. One copy will be returned to the applicant with comments.

[] 2. Include a detailed site map on a separate sheet of paper, showing the location of the tanks(s), piping, streets, adjacent properties (north toward the top of the page), nearby septic tanks, leachfields, water wells, buildings, underground public utility lines (including water, sanitary sewer and storm sewer), and distance of piping from tank to dispensers. If underground utilities are not included on the site map, you must state in writing that USA Dig will be contacted prior to

excavation activities.

[] 3. Complete pages 3-6, "Application for Underground Storage Tank Closure Permit". •-0•: Sampling firm shall be an independent third part,/from the contractor.

[] 4. Complete page 9, "Authorization to Release". This form must be signed and dated by the OWNER/OPERATOR of the facility.

[] 5. Submit a "Service Request" form with the appropriate fees, submit completed UPC forms for Facility and Tanks (formerly State A & B forms) and complete the "Underground Storage Tank Program Fee Worksheet".

[] 6. Complete all questions on page 10, the Environmental Health Department (EHD) "Underground Storage Tank Disposition Tracking Record", except those requiring a signature and date of tank removal. The holder of the permit shall be responsible for ensuring that this form is completed and returned to EHD within 30 days of the tank removal.

[] 7. Submit a "Site Health & Safety Plan" as an addendum to this application, to address all potential hazards for this specific job site. Refer to the Site Safety Plan Guidance Document for specifics.

[]

[]

8. If facility is located outside of the city limits, submit a "Backfill Excavation Certificate" as required by the County of San Joaquin Building Department and the incorporated City Building Departments, pursuant to the Uniform Building Code STD 70-1 I.

9. Obtain a "Grading and Excavation Permit" from the City of Tracy Building Division prior to EHD approval of the closure plan.

[] 10. The maximum review time for Closure Plans is 15 working days from receipt of the adequately completed plan. If

gross deficiencies are identified, an addendum will be required with a $98.00/hour fee and the review will begin on the date of resubmittal.

1. Submit verification of the fire permit from the appropriate fire district at the removal inspection.

[] 12.

[] 13.

Advance inspection notice of at least 48 hours is required by EHD.

Submit Contingency Plan for over-excavation at time of UST removal (if planning to over-excavate). See "III. SITE MITIGATION" on Page 2.

EH23 046 (Revised 12/31/07) 1

II. GENERAL INFORMATION:

Obtain an EPA Site Number from the Department of Toxic Substances Control (800) 61-TOXIC for temporary hazardous waste removal activities associated with underground storage tank (UST) removals.

Disposal Information: SJC EHD's Underground Storage Tank Disposition Tracking Record (UST Tracking Record, page 10) shall accompany each tank removed from site. Tank(s) will be issued an identification number which EHD's representative will note on the UST Tracking Record. Contractor will affix same

identification number onto tank end using fluorescent spray paint. Contaminated tanks and/or piping are to be transported under Hazardous Waste Manifest by a state registered hazardous waste hauler.

Contractor to Provide: Combustible/Flammable gas detector (to verify the Lower Explosive Limit (LEL) atmosphere and oxygen level of tank prior to lifting from excavation), adequate number(s) and appropriate type(s) of fire extinguisher(s), barriers to secure the area as necessary to minimize traffic and pedestrian interference, and fluorescent spray paint to affix tank identification numbers. It shall be the project manager's responsibility for compliance with all health & safety regulations and requirements, which shall be strictly adhered to at all times during the course of the closure activities.

4 The EHD permit shall be on site during tank excavation and removal.

5. Any changes in this document shall be approved by EHD prior to initiating work.

Closure-in-Place: If Closure-in-Place is the suggested method of abandonment, complete form EH 23 039 and submit written approval from the local Fire Department.

Temporary Closure: If Temporary Closure is the suggested method of abandonment, complete and submit this application and include an explanation of how the UST owner/operator will comply with California Code of Regulations Title 23, Section 2671 (a)-(e). Also, submit a written approval from the local Fire Department.

The following documentation shall be submitted within 30 days of the tank removal date:

a) Analytical results, mailed directly from laboratory to EHD, including a chain of custody and quality assurance and quality control (QA & QC).

b) UST Tracking Record Sheet(s) and/or Tank Hazardous Waste Manifest(s).

c) Tank Closure Certification Form (DTSC form 1249).

d)

e)

Hazardous Waste Manifests for piping, rinsate, residual fuel, or waste oil receipt.

Submit the backfill excavation certificate as required by San Joaquin County and the incorporated City Building Departments. This report will be referred to the appropriate agency for their review.

A site which has had UST(s) removed, shall not be considered for final closure until the above items are

submitted for review.

III. SITE MITIGATION:

In the event contamination is observed, confirmed or suspected as a result of a leaking UST system it is the responsibility of the owner or operator to submit a work plan to EHD Site Mitigation Unit and have it approved prior to initiating any assessment or remediation activities. To minimize delays, the work plan may be submitted

concurrent with tank closure or installation plans. Address one copy of the work plan to the Site Mitigation Unit for review. If the site is not currently in the Local Oversight Program, a billing form and a $294 minimum fee

must be submitted with the work plan. For further assistance contact the Site Mitigation Unit at (209) 468-3450.

EH23 046 (Revised 12/31/07) 2

ENVIRONMENTAL HEALTH DEPARTMENT SAN JOAQUIN COUNTY

APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT

THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE TANK(S) EXPIRES 180 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS, INDICATE PERMIT TYPE:

[] REMOVAL [] TEMPORARY CLOSURE [] CLOSURE IN PLACE FACILITY INFORMATION

EPA SITE # PROJECT CONTACT PHONE#

FACILITY NAME PHONE #

ADDRESS

CROSS STREET

OWNER OPERATOR PHONE #

CONTRACTOR NAME

CONTRACTOR INFORMATION PHONE#

CONTRACTOR ADDRESS CA LIC # CLASS

INSURER

FIRE DISTRICT

LABORATORY NAME SAMPLING FIRM

WORKER COMP#

PERMIT #

COUNTY [PHONE# PHONE#

TANKID#

39- 39- 39- 39- 39- 39-

TANK SIZE

TANK INFORMATION TANK CONTENTS (PRESENT & PAST) DATE INSTALLED

APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS, AND RULES AND

REGULATIONS OF SAN JOAQUlN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE

FOLLOWING: "1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, SHALL NOT EMPLOY ANY PERSON IN SUCH

A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING

SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, SHALL

EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA."

APPLICANT'S SIGNATURE TITLE DATE

[] APPROVED [] APPROVED WITH CONDITION(S) [] DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATrACHMENT)

PLAN REVlEWER'S NAME DATE

ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS:

EH 23 046 (Revised 12/31/07) 3

(a) Is there a EHD contractor's and subcontractor's questionnaire on file or enclosed? (b) Is the current certificate of worker's compensation insurance on file? (c) Does the contractor possess a "•Iazardous Substance Removal Certification"? (d) Has everyone on site, including crane/backhoe operator, been certified to work on

hazardous waste site in accordance with CCR Title 8?

YEs[] NO [] YES[] YES []

YES[] NO[]

Has a "Site Health & Safety Plan" for this job site been submitted? YES[] NO[]

Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? N/A YES NO If YES, Permit #

Has the contractor obtained approval from the local fire department to perform tank cutting? NA[ YES[ NO[

Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES NO

NO[] NO[]

If tank residual exists, identify transporting hazardous waste hauler:

Name Hauler Registration #

Address City Zip

Phone # ).

Decontamination Procedures:

a. Will tank(s) and piping be decontaminated prior to removal? YES NO

b. Identify contractor performing decontamination:

Name

Address City Zip

Phone No.(

Describe method to be used for decontamination:

d. Describe how rinsate material will be stored onsite prior to manifesting offsite:

ao

Hauler Name

Address

Phone No.

Rinsate Hauler and permitted Treatment, Storage & Disposal Facility:

Hauler Registration #

City Zip

Permitted Disposal Site

Describe the method that will be utilized to purge and/or inert the tank(s):

Tank/Piping Hauler:

Name

bo

EH23 046 (Revised 12/31/07) 4

Address City_ Zip

Phone No.( )

Hauler Registration # (if hauled as hazardous)_

Tank/Piping Disposal Site:

Name

9o

Address City. Zip.

Phone No.(

EPA ID# (if transported to a permitted TSD facility)

Is the sampling firm an independent third party from the contractor? YES NO

Describe, in detail, how the soil and/or water sample(s) beneath the tank and piping will be obtained:

10. Describe how the excavation will be backfilled with suitable material upon removal:

11. Handling of excavated soil:

a) What material will be used to line the tank pit and cover the stockpile?

b) What will be the final destination of the excavated stockpile?

12.

c) Contaminated Soil Hazardous Waste Hauler:

Name

Address

Phone No.

City

Hauler Registration #

Zip

What is the depth to groundwater? Describe the source of information:

EH 23 046 (Revised 12/31/07) 5

13. Are there any water wells on this parcel or adjacent properties? YES NO

TYPE OF WELLS

Public Well

Private Well

Irrigation Well

Monitoring Well

Other

DISTANCE TO TANKS(S)

14. Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES[ NO[

15. Indicate the responsible party to be billed for additional EHD staff time expended beyond 3 hour minimum permit payment per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the billing by signature and date below.

Name

Mailing Address

Day Phone Number

Signature Title Date

EH 23 046 (Revised 12/31/07) 6

SAMPLING PROTOCOL FOR ROUTINE TANK REMOVALS

The following represents minimum sampling criterion required for closure compliance. Soil samples collected shall be representative of native soils beneath the tank's invert (tank's bottom) at a collection depth not to exceed 2 4 feet. If contamination is documented during closure, an Unauthorized Release Notification must be completed and submitted within five (5) working days pursuant to

California Health & Safety Code, Section 25295.

WATER NO.__•.T PRESENT IN THE TANK PIT

TANK #

TANK SIZE (Gallons)

< 1,000

1,000- 10,000

> 10,000

MINIMUM NUMBER of SOIL SAMPLES

per Tank

2 per Tank

3 or More

per Tank

LOCATION OF SOIL SAMPLES

Fill OR Pump End of Tank

at each End of Tank

Ends and Middle OR generally spaced along the length of the Tank

PIPING AND STOCKPILE

PIPING SOIL SAMPLES

TANK & PIPING STOCKPILE SAMPLES

Sample every 20 lineal feet

2 Samples every 50 cubic yards

WATER IS PRESENT IN TANK PIT

TANK TANK SIZE # (Gallons)

< 10,000 Single Tank

> 10,000 OR Tank Cluster


5 or more

LOCATION of SOIL SAMPLES

2 from wall next to tank ends at soil/groundwater interface & below tank

4 from wall next to tank ends at soil/groundwater interface & below each tank

MINIMUM NUMBER of WATER SAMPLES

SLAB PRESENT IN THE TANK PIT Soil samples shall be obtained beneath the slab within native soils. Penetration through the obstruction will be required in order to

collect the samples. (Physical removal of the obstruction will allow sampling according to the above conditions.)

TANK TANK SIZE # (Gallons)

< 1,000

1,000- 10,000

> 10,000


3 per Tank

5 per Tank

5 OR More per Tank

LOCATION of SOIL SAMPLES

Center and Ends OR Sides of Tank

Center and Ends OR Sides of Tank

Ends and Middle and generally spaced along the length of the Tank

EH 23 046 (Revised 12/31/07) 7

Tri-Regional Recommendations Appendix A

TANK #

TABLE #2 RECOMMENDED MINIMUM VERIFICATION ANALYSES FOR UNDERGROUND STORAGE TANK INVESTIGATIONS

TANK CONTENTS

TPH-G TPH-D BTX & E CL HC TOTAL MTBE LEAD

8015 8015 8020 8010 8020 8260 8260 8260 8240 7420 8260

8260 7421

OXYGENATES METALS PCB

(MTBE, TBA, DIPE, ICAP/AES 8270

ETBE, TAME) or 8080

1,2 DCA & EDB AA 8260

LEADED GAS

UNL GAS

DIESEL

KEROSENE

UNK FUEL

PROD. OIL

CHLOR. SOLVENTS

NONCHLOR SOLVENTS

X X X X

X X

X X

X X X

X X X X

X X X

X X X

X X X

X

X

WASTE\USED OIL

OR

UNKNOWN CONTENTS

X X X X X X X

Notes: 1. EPA Method 8260B analyses must include all analytes listed in the method plus fuel oxygenates methyl-

tertiary-butyl ether (MTBE), diisopropyl ether (DIPE), ethyl-tertiary-butyl ether (EtBE), tertiary-amyl-methyl ether (TAME), tertiary-butanol (TBA), methanol and ethanol and fuel additives 1,2-dichloroethane (1,2-DCA) and ethylene dibromide (EDB or 1,2-dibromoethane).

2. If pentachlorophenol (PCP) is identified, analyze the soil and/or water sample for dioxins and furans by EPA Method 8290 and pesticides by EPA Method 8081A.

3. METALS ICAP or AA Inductively Coupled Plasma Atomic Emission Spectrometry 6010 or Atomic Absorption Spectrometry 7000. Metals: Cadmium, Chromium III and Vl, Lead, Zinc and Nickel.

4. Non-proprietary, performance based analytical methods may be used with approval of Regional Board staff.

EH 23 046 (Revised 12/31/07) 8


Telephone: (209) 468-3420 Fax: (209) 468-3433

AUTHORIZATION TO RELEASE

* ANALYTICAL RESULTS

* GEOTECHNICAL DATA

* ENVIRONMENTAL/SITE ASSESSMENT INFORMATION

I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY

LOCATED AT

HEREBY AUTHORIZE

(Street Address) (City)

(Laboratory)

TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE.

BUSINESS NAME: (If Applicable)

OWNER/OPERATOR: (Please PrinO (Title)

(Owner/Operator Signature) (Date)

ADDRESS: (Mailing Address)

(City) (State) (Zip Code)

PHONE:(

EH 23 046 (Revised 12/31/07) 9


Telephone: (209) 468-3420 Fax: (209) 468-3433

UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD

SECTION 1 SJC Environmental Health Department's Tank Tracking Sheet shall accompany each tank affixed with its site identification number. The Tank Tracking Sheet is to be returned to the Environmental Health Department within 30 days of

acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is completed and returned.

FACILITY NAME:

FACILITY ADDRESS:

TANK ID #39 TANK SIZE: PREVIOUS TANK CONTENTS:

SECTION 2 To be filled out by tank removal contractor:

Tank Removal Contractor:

Address: City:. Zip:

Phone #: (___). Date Tank Removed:

SECTION 3 To be filled out by contractor "decontaminating tank":

Tank Decontamination Contractor:

Address: City: Zip:.

Phone #: (___).

Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved manner as required by Cal EPA.

Name: Title: Signature: Date

SECTION 4 To be signed and dated by an authorized representative of the treatment, storage, or disposal facility accepting tank and/or piping.

Facility Name:

Address:

Phone #: (.__

City:. Zip:

Date Tank Received:

Name: Title: Signature: Date

EH 23 046 (Revised 12/31/07) 10

BACKFILL EXCAVATION CERTIFICATE

Project Location:

Owner:

Contractor:

License No:

Phone No:

Phone No:

INDICATE METHOD OF BACKFILL QUALITY ASSURANCE

1. Submission of Soil Engineer's Compaction Report within 30 days of project completion, or

2. Submission of verification e.g. load ticket, within 30 days of project completion that one of the fo owing matenals was placed 'n the excavat'on n 12" lifts:

Ao Pea gravel--smooth, rounded material not more than one-half (1/2) inch •n diameter

Crushed rock--self-compacting material not more than three-quarters (3/4) inch in cross sectional measurement. (Use of crushed rock will not be permitted for backfill if contact will be made between the backfill material and tanks/pipes made of poly resin glass or similar materials.)

DECLARATION

hereby cert fy that a Soil Engineer's Compaction Report will be submitted within 30 days of project completion, or submission of verification thatthe select material described above w /be placed at a minimum of five (5) cubic yards per 1000 gallon tank displacement and that the entire excavation will be backfilled and compacted to insure compliance with the Uniform Building Code Appendix Chapter 70.

*Name (Print)

*Title (Print)

*Signature

Shall be the responsible managing employee on the license or authorized agent.

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT

600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 VCeb: www.si•ov.org/ehd

FACILITY NAME FACILITY CONTACT NAME

FACILITY ADDRESS SITE PHONE # WITH AREA CODE

CITY STATE

CA

ZIP CODE # OF TANKS AT SITE

APPLICANT BILLING NAME APPLICANT CONTACT NAME

APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE

CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC #

Closure Installation Repair Retrofit

ACTIVE FACILITY

$500 FEE INCLUDES FACILITY FEE TANK (2002-2007) $550 FEE INCLUDES FACILITY FEE TANK (2008) $125 PER TANK AFTER FIRST TANK

TANK PENALTY ASSESSED

TANK SURCHARGE $15 TANK

2003 2004 2005 2006 2007 2008

$

$

$

STATE SURCHARGE FOR FACILITI.ES NOT ALREAD, Y ON INVENTORY, iN A CUPA PROGRAM =$24.00/FACILITY,

PERMANENT CLOSURE Removal or Permitted Closure in Place)

TANK ID # (s) TEMPORARY CLOSURE Plan Review and Inspections)

CLOSURE FEE $294 TANK # TANKS X $294

TANK ID # (s) TEMPORARY CLOSURE FEE $294 FACILITY

$

$

INSTALLATION PLAN CHECK (Plan Check and Construction Inspections)

TAN, K lO, # (§): PLAN CHECK FEE $784 FACILITY

REPAIR PLAN CHECK

TANKID#(s):

TANK RETROFIT REPAIR FEE $294 FACILITY (use for monitoring equipment, cold starts, EVR upgrades, spill buckets, sumps, misc.)

PIPING REPAIR FEE $294 FACILITY (use for piping, under-dispenser containment, ect.)

MISCELLANEOUS

TRANSFER FEE $ 20 $

CONSULTATION FEE $ 98/HOUR $

UNAUTHORIZED RELEASE EVALUATION FEE $ 98 HOUR $

SAMPLING INSPECTION FEE $ 98/HOUR ALL FEES ARE BASED ON THE $98 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT.

OFFICE USE ONLY SERVICE'REQUEST # FACILITY iD

SR EH 23 032 (REVISED 12131107)

AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT

SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST #

OWNER OPERATOR CHECK if BILLING ADDRESS

Street Name

FACILITY NAME

SITE ADDRESS

Street Number Direction City HOME or MAILING ADDRESS (If Different from Site Address)

Street Number Street Name

CITY STATE ZIP

PHONE #1 ExT. APN # LAND USE APPLICATION #

ExT. BOS DISTRICT

Zip Code

PHONE #2 LOCATION CODE

CONTRACTOR / SERVICE REQUESTOR REQUESTOR

CHECK if BILLING ADDRESS

BUSINESS NAME

HOME or MAILING ADDRESS

PHONE#

FAx#

EXT.

CITY STATE ZIP

BILLING ACKNOWLEDGEMENT: i, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form.

also certify that have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws.

APPLICANT'S SIGNATURE: DATE:

PROPERTY BUSINESS OWNER [] OPERATOR MANAGER [] OTHER AUTHORIZED AGENT [] If APPLICANT iS not the B/LUNG PARTY, proof of authorization to sign is required Title

AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative.

TYPE OF SERVICE REQUESTED:

COMMENTS:

P/E:

ACCEPTED BY: EMPLOYEE #: DATE:

ASSIGNED TO: EMPLOYEE #: DATE:

Date Service Completed (if already completed): SERVICE CODE:

Fee Amount: Amount Paid Payment Date

Payment Type Invoice# Check# Received By:

EHD 48-02-025 .R....E.VISED 11/17/2003

SR FORM (Golden Rod)

APPENDIX D

ENVIRONMENTAL HEALTH DEPARTMENT

Donna K. Heran, R.E.H.S. Director

Laurie A. Cotulla, R.E.H.S. Assistant Director

SAN JOAQUIN COUNTY 600 East Main Street

Stockton, California 95202 Telephone: (209) 468-3420

Fax: (209) 468-3433

Program Coordinators Carl Borgman, R..E.H.S.

Mike Huggins, R.E.H.S., R.D.I. Margaret Lagorio, R.E.H.S. Robert McClellon, R.E.H.S.

Jeff Carruesco, R.E.H.S. Kasey Foley, R.E.H.S.

CLOSURE IN PLACE

Business/Owner's Name: Facility Address: Tank(s) Number: Applicant's Name: Phone No: Date Submitted:

1. Local County/City Fire District shall approve the Closure in Place (CIP) prior to Environmental Health Department (EHD) approval.

2. A registered geologist or qualified consultant shall submit/sign the CIP proposal.

3. The applicant shall complete the "Application for Permit to Close Underground Storage Tanks Storing Hazardous Materials" form and remit a $294 review fee. Any additional review time required will be assessed at $98 per hour.

4. The applicant shall submit a technical work plan 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) f) 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.

5. The applicant shall complete the "Application for Permit SJCEHD" and remit $89 boring permit fee. a) An initial fee of $89 includes the first hour of inspection time. If additional inspection time is required,

a $98 per hour 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 SJCEHD" form and $89 permit fee is required for

each separate parcel. d) The drilling contractor performing work must have on file:

o A copy 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.

7. A notice to be placed on the deed of the property (describe exact vertical and aerial location of the closed UST, the hazardous substances it contained, and the closure method).

[] 8. Approved by REHS: Date:

EH 23 039 (Rcv 8/3/07)

APPENDIX E

Stockton Fire Department • Fire Prevention Division 345 N. El Dorado Street, Stockton, CA 95202

(209) 937-8271 • Fax (209) 937-8893

ONE TIME FIRE PERMIT INSPECTION, APPLICATION made for a time fire the

Application Date:

Describe Type of Event

Event Location: City [] County []

Event Address Suite• Zip

Applicant or Business Name

IF APPLICABLE: Stockton Business License # Expiration Date

Applicant's Address Suite• Zip. Contact Person Contact Phone

APPLICANTS PIlce I che•k v" next to permit y•u are applying fort

Type of Permit

Asbestos Removal per event/one time permit

Bowling Alley-pin/alley refinishing per event/one time permit Candles & Open Flames in Assembly Areas

per event/one time permit

Carnivals & Fairs per event/one time permit

Installation of underground tanks per event/one time permit Removal of commercial underground tank per event/one time permit Tank lining of above/underground tanks per event/one time permit Fumigation and/or Thermal Insecticidal Fogging- per event/one time permit

Type of Permit Liquid/gas Fueled Vehicles or Equipment in Assembly Buildings per event/one time permit Mall used as a Place of Assembly per event/one time permit

Open Burning- per event/one time permit

.. Parade with Floats, per float per event/one time permit Tent Short term I month or less per event/one time permit Christmas Trees; when placed in public building- per event/one time permit

OTHER per event/one time permit (explain)

ALL APPLICANI'$ READ AND SIGN •L INFORMATION IS SUBJECT TO VERIFICATION

have read this application and know the contents thereogpnd attest that the same is true and correct. further acknowledge that the City of Stockton has adopted the/=ire Code, and the amendments thereof,

and use of the permit being applied for will conform to accepted standards.

APPLICANT SIGNATURE DATE

BELOW FOR OFFICE USE ONLY

•IUMBER INSPECTION PERMIT T• (o time permlt) •

Dateissued• i • ::. R6

INSPECTION RESULTS:

INSPECTED BY:

07/01/o8 FPD FORM PermitApplicaSon

DATE

White: FPD File Yellow; Inspecttbn Results to Customer Pink: Payment Copy to Customer

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