Laserfiche WebLink
I <br />I <br />NAME OF FACILITY <br />ADDRESS <br />TANK SIZE G Poo <br />fl. GENERAL SITE HISTORY <br />SAN JOAQU iN C PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALD IVISION <br />WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br />0,1 1 0' n SWEEPS CODEEI y / <br />ZC S. S k- TANK ID <br />FUEL TYPE J JX ,, _t I <br />Is permit current? <br />Yes <br />o <br />PE:#[e- <br />Yes <br />Ret/Year <br />Facility Status Code <br />G <br />! <br />Doc.Soil/GW Cont <br />•te <br />Yes <br />Was a repair made to the tank system? <br />No <br />No <br />Number of Tanks at <br />facility, <br />2— <br />Age <br />of Tanks(if available) <br />v <br />T ype of Tank <br />Steel <br />soil samples ana lyzed7 <br />Fbrgl <br />S <br />C <br />0 <br />R <br />E <br />Sngl <br />Dual <br />ST%E <br />III. TANK HISTORY <br />Was Tank tested? <br />Yes I <br />No <br />Failed precision test t <br />Yes <br />Ret/Year <br />No <br />If <br />yes, give date(s) <br />14 <br />Was a repair made to the tank system? <br />Yes <br />No <br />f yes, what was repaired? <br />Was repair done under inspection? <br />Yes <br />lrr <br />No <br />dWere <br />soil samples ana lyzed7 <br />Yes <br />S <br />C <br />0 <br />R <br />E <br />No <br />S <br />C <br />0 <br />R <br />E <br />ST%E <br />S <br />C <br />0 <br />R <br />E <br />TPH-G <br />Distance to Well(s) from Tank�' <br />TPH-D <br />Pb/EDB <br />Minimum Depth to groundwater from the Soil Sample (feet) <br />Type of failure/discharge <br />catastrophic <br />long-term leakage <br />overfill <br />Fractures in subsurface (applies to foothills or mountain areas) <br />known <br />None <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 />/r'r— <br />Ret/Year <br />Average Arcual Precipitation <br />A= <br />14 <br />10-25 <br />On -Site Wells) <br />Yes <br />No <br />Number 8 Type <br />lrr <br />Dom <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 />Store <br />5 pts <br />if <br />condition <br />is met <br />Distance to Well(s) from Tank�' <br />C'�ft; ft; ft <br />1. Site Feature - Leaching Potential Analysis <br />Minimum Depth to groundwater from the Soil Sample (feet) <br />-- <br />>100 <br />51-100 <br />25-50\1 <br />Fractures in subsurface (applies to foothills or mountain areas) <br />I U <br />None <br />Unknown <br />Present <br />Average Annual Precipitation (inches) <br />xxxxxx <br /><10 <br />9 <br />10-25 <br />xxxxxxx <br />26-40\2 <br />Man -Made conduits which increase vertical migration <br />of leachate (i.e., septic systems, water wells, ponds) <br />I O <br />None <br />— <br />Unknown <br />Present <br />Unique site features: Recharge area, coarse soil, nearby wells. <br />xxxxxx <br />None <br />At least <br />one <br />More than <br />one <br />COLUMN TOTALS>>>TOTAL POINTS <br />ZE) <br />+ <br />+ <br />s <br />Sample Result: (B T X OR E) <br />RANGE OF TOTAL POINTS <br />49 pts or more <br />41 - 4a pts <br />40 pts or less <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) <br />B <br />1 <br />T <br />50 <br />% <br />50 <br />E <br />50 <br />B <br />.3 <br />T <br />.3 <br />X <br />1. <br />E <br />1. <br />NA\3 <br />Sample Result: <br />TPN <br />GASOLINE <br />MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br />DIESEL <br />1000 <br />100 <br />10 <br />10,000 <br />1000 <br />100 <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 LOT Contamination List for soil or ground water.) <br />\1 If depth is > 5 ft. and < 25 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 TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br />VI. STAFF RECOMMENDATION/CONCLUSION <br />1. Are BTX 8 E or TPH Concentrati ors > Allowable Levels •Yes No <br />2. Recommend Site Closure Yes No If Yes, Refer to Site Mitigation for Evaluat <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 />NO <br />DATE REFERRED <br />/ / <br />DATE CLOSURE LETTER MAILED <br />NAME OF <br />EVALUATOR <br />EN 23 80 (UGTWKSHT)\5/90 b I <br />