Laserfiche WebLink
SAN JOAQUIN COL PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL mIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION .... DATE y <br /> (NAME OF FACILITY ,o �'S y3< �ncu�Jr�cC'eSWEEPS CODE <br /> r�n� /Cb9 <br /> .ADDRESS aS1U AJ, TANK ID 0 3e/ - /C?,?-7 <br /> c.. <br /> WANK SIZE 5 Cz FUEL TYPE al((e Se f <br /> GENERAL SITE HISTORY <br /> *** <br /> is permit current? Yes y No Permit S - Facility Status Code Doc.SOi I/GW Cont Yes No <br /> Number of Tanks at facility y Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual <br /> :I. TANK HISTORY <br /> !,Was Tank tested? Yes No Failed precision test 7 Pas No — Ifyes, give date(s) <br /> Was a repair made to the tank system? Yes No 14,f yes, what was repaired? <br /> 'Was repair done under inspection? Yes No Were soil samples analyzed? Yes No BT%E TPH-G TPH-D Pb/EDB <br /> Type of failure/discharge catastrophic long-term leakage overfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Ground Water y O Ref/Year G; Average Annual Precipitation A-114 10-25 <br /> On-Site WeLL(s) Yes No 1,jNumber & Type Irr Dan Pub <br /> _ S Score S Score 5 Score <br /> Distance to Well(s) from Tank ft; — ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R condition R condition R condition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet) >100 51-100 s" 25-50%1 <br /> ,Fractures in subsurface (applies to foothills or mountain areas) .� (� None Unknown Present <br /> 'Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> -n-Made conduits which increase vertical migration <br /> Leachate (i.e., septic systems, water wells, ponds) None Unknown Present <br /> lunique site features: Recharge area, coarse soil, nearby wells. C7! At least More than <br /> jxxxxxx None I one one <br /> COLUMN TOTALS>>>TOTAL POINTS 2 D + + S = 3 <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or Less <br /> B T X E B T I X E <br /> �Y MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> (Sample Result: GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH DIESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contaminatim is present, do 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. <br /> \3 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAF- RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No <br /> 2. Recommend Site Closure Yes I 4No If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISCIR/SgMIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUA70R <br /> EH 23 80 (UGTWKSHT)\5/90 <br />