Laserfiche WebLink
f. <br />NAME OF FACILITY <br />ADDRESS 3 <br />i:TANK SIZE 110 n -o <br />;1. GENERAL SITE HISTORY <br />Is permit current?Yes <br />,Number of Tanks at facil <br />'11. TANK HISTORY <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br />WORKSHEET FOR SITE CLOSURE EVALUATION DATE s ��Z – <br />\ /L [ N SWEEPS CODE G, /6` Com``/ <br />ZC7 S. ��c ��y^ TANK ID%LO�OI–�� <br />FUEL TYPE 1 n, , _ I <br />'ermit #I - (Facility Status Code) 9GJ IDoc.Soil/GW Cont IYesl N <br />-ZjAge of Tanks(if available) v 0 / Type of Tank Steel brgl Sngl Dust <br />Tanks(if available) v 0 / Type of Tank Steel brgl Sngl Dual <br />Was <br />Tank tested? <br />Yes <br />No <br />o <br />Depth to Ground Water <br />Failed precision test 7 <br />Yes <br />��; <br />No <br />A= <br />f as, give date(s) <br />10-25 <br />Was <br />a repair made to the tank system? <br />Yes <br />No <br />If yes, what was repaired? <br />Was <br />repair done under inspection? <br />Yes <br />No <br />Were soil samples analyzed? <br />Yes <br />No <br />TXE <br />TPH-G <br />TPH-D <br />Pb/EDB <br />Type <br />of failure/discharge <br />catastrophic <br />S <br />C <br />0 <br />R <br />E <br />long-term Leakage <br />S <br />C <br />0 <br />R <br />E <br />overfill <br />S <br />C <br />0 <br />R <br />E <br />unknown <br />Distance to WeLL(s) from Tank <br />other: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />Soil Samples Received <br />Yes <br />No <br />Depth to Ground Water <br />c6 <br />Ref/Year <br />��; <br />Average Annual Precipitation <br />A= <br />14 <br />10-25 <br />On -Site Wel t(s)Yes <br />No <br />Number 8 Type <br />Irr <br />Dam <br />Pub <br />S <br />C <br />0 <br />R <br />E <br />Score <br />10 pts <br />if <br />condition <br />is met <br />S <br />C <br />0 <br />R <br />E <br />Score <br />9 pts <br />if <br />condition <br />is met <br />S <br />C <br />0 <br />R <br />E <br />Score <br />5 pts <br />if <br />condition <br />is met <br />Distance to WeLL(s) from Tank <br />2:Lx_ L; ft; ft <br />V. Site Feature - Leaching Potential Analysis <br />Minimum Depth to groundwater from the Soil Sample (feet) <br />>100 <br />51-100 <br />25-50\1 <br />Fractures in subsurface (applies to foothills or mountain areas) <br />O <br />None <br />-- <br />Unknown <br />.--_ <br />Present <br />Average Annual Precipitation (inches) <br />xxxxxx <br /><10 <br />9 <br />10-25 <br />xxxxx:0: <br />26-40\2 <br />Man -Made conduits which increase vertical migration <br />of leachate (i.e., septic systems, water wells, ponds) <br />(' <br />more <br />— <br />Unknown <br />Present <br />Unique site features: Recharge area, coarse soil, nearby wells. <br />At least <br />More than <br />xxxxxx <br />None <br />one <br />one <br />COLUMN TOTALS>»TOTAL POINTS <br />Z <br />+ <br />l <br />+ <br />Sample Result: IS; T X OR E) <br />RANGE OF TOTAL POINTS <br />49 pts or more <br />41 - 48 pts <br />40 pts or loess <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) <br />B <br />1 <br />T <br />50 <br />XE <br />50 <br />50 <br />B <br />.3 <br />T <br />.3 <br />% <br />1. <br />E <br />1. <br />NA\3 <br />Sample Result: <br />IrASOLINE <br />MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br />iC00 <br />100 <br />10 <br />10,000 <br />1000 <br />100 <br />TPH <br />DIESEL <br />FOOTNOTES: '•*If documented soil and/or ground water contamination is present, do not complete the leaching potential <br />analysis. (i.e., site is currently on UGT Contami ation List for soil or ground water.) <br />\1 If depth is > 5 ft. and < Z5 ft., score 0 points. If depth <=5 ft., do not use table. <br />\2 If precipitation is > 40 inches, score 0 points. <br />\3 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br />V1. STAFF RECOMMENDATION/CONCLUSION <br />1. Are BTX 8 E or TPH Concentrations > Allowable Levels 'Yes No <br />2. Recommend Site Closure l Yesl jNol I• -if Yes, Refer to Site Mitigation for Evaluation <br />VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br />CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE <br />YES <br />NO <br />REFERRED TO SITE MITIGATION FOR EVALUATION <br />YES <br />I <br />NO <br />DATE REFERRED <br />/ / <br />DATE CLOSURE LETTER MAILED <br />NAME OF <br />EVALUATOR <br />mn U ou tuulw6Snl)�D, ^J 6 <br />