Laserfiche WebLink
SAN JOAQUIN CCUHTI BLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH SION <br /> ( UGS KSHEET FOR SITE CLOSURE EVALUATION PS DATE c <br /> SWEEPS CODE <br /> NAME OF FACILITY u 5 <br /> _ TANK !D # $ <br /> ADDRESS <br /> TANK SIZE 5;IoCK FUEL TYPE /P C' <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? Yes No Permit # Doc.Soil/GW Cont Yes No <br /> Nu berE of Tanks at facility �ofs(if available) Type of Tank Steel rgl Sngl Dual <br /> 111. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test 7 Yes No If yes, give date(s) <br /> Was a repair made to the tank system? Yes No f yes, what was repaired? <br /> Was repair done under inspecti ont 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 Vater 3S Ref/Year 1��� Average Annual Precipitation A= 14 10-25 <br /> On-Site Wells) Yes No Number i Type Irr Dam Pub <br /> S Score S Score S 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 Aria lysis E is met E Is met E Is met <br /> Minimum Depth to groundwater from the Soil Semple (feet) j 5 <br /> / >100 51-100 <br /> Fractures in subsurface (applies to foothills or mountain areas) <br /> None C, Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migrationNone cy Unknown Present <br /> of leachate (i.e., septic systems, water wells, ponds) / <br /> At least More than <br /> Unique site features: Recharge area, coarse soil, nearby wells. xxxxxx None l one one <br /> COLUMN TOTALS>»TOTAL POINTS U t 3kr� � <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 61 — 48 pts 40 pts or—Lie ss <br /> \/ B T % E B T % E <br /> d(/fi ��/ MAXIMUM ALLOWABLE B-T-%-E LEVELS (PPM) 1 50 50 .3 .3 i. 1. NA\3 <br /> Sam a Resul <br /> GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPN LEVELS (PPM) .- 100 <br /> DIESEL 10,000 00- -- <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 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 BT%8E are rot applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppmm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No <br /> 2. Recommend Site closure Yes No *If Yes, Refer to Site Mitigation for Evaluation n�Vo�i�„ �G Z P <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR L• <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE yES7 NO 7REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER NAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 BO (UGTWKSHT)\5/90 <br />