Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION 1I <br /> T• UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY `n�c ;i WEEPS CODE <br /> DDRESS -2,-7 3 +� ft Uke ITANK ID # <br /> ANK SIZE 00V UEL TYPE n � <br /> 11. GENERAL SITE HIST Y <br /> 1s permit current? es o ermit # acility;Status Code oc,Soil/GW Cont es o <br /> I <br /> umber of Tanks at facility Lge of Tanks(if available) ! ype of Tank teel Fbrgl ngl Dual <br /> 111, TANK HISTORY <br /> as Tank.tested? ES o ailed precision test ? es ::E <br /> Ifillyes; give date(s) <br /> f as a repair made to the tank system? es No f yes, what was repaired? <br /> ns repair done under inspection? es No ere Soil samples analyzed? es Jo TXE PH-G PH-D b/EDG I� <br /> 1 <br /> ype of failure/discharge atastrophic Long-term leakage verfill I inknownthen: i <br /> 1V, REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es 10, 1 epth to Ground Water of/Year • ' 3 verage Annual Precipitation k= 114- 10-25 - <br /> -site Wells) es o umber & Type Irr om ub <br /> S core 5 core S core <br /> )i stance to Welts) from Tank .� ft; ft; ft C 10 pts C 9 pts C r5 pts <br /> 0 if 0 if 0 if ; <br /> R ondition R condition R ondition <br /> . Site Feature - Leaching Potential Analysis E f is met E is met E is met „> i <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 25-5011 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown _� resent <br /> Average Annual Precipitation (inches) xxxxx <10 9 10 25xxxxxx 26 40\2 <br /> nn-Made conduits which increase vertical migration <br /> Df leachate (i.e., septic systems, water wells, ponds) None Unknown resent= 1 <br /> lnique site features: Recharge area, coarse soil, nearby wells: (�,{ At least ore than- <br /> xxxxx None v( one awe <br /> l <br /> COLUMN TOTALS»>TOTAL POINTS I o� + + 42— <br /> ample sulo�POM, <br /> B X OR E) RANGE OF TOTAL POINTS 9 ptslor more 41 - 48 pts 40 pts or Less <br /> ' ► ire; , J <br /> +< 4 B T I X E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 501 50 50 .3 .3 1. 1. NA\3 <br /> A <br /> "ample Result: ASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPN LEVELS.(PPM) <br /> A/D TPH IESEL. 10(000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is p3resent, not complete the Leaching potential <br /> analysis. (i.e., site is currently on UGT 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. 1� <br /> \3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes o _� <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigatioe for EvaLuation <br /> V11. REVIEW EVALUATION - TO BE C014PLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION fOR CLOSURE ES 0 EFERRED TO SITE+ MITIGATION FOR EVALUATION ES D I <br /> ATE REFERRED / / ATE CLOSURE: LETTER MAILED4AME OF <br /> { � L <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />