Laserfiche WebLink
SAN JOAOUIN COUP" OUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH an41D <br /> 1. U )ORKSHEET FOR SITE CLOSURE EVALUATION —2 <br /> D y-^'/ - SWEENAME OF FACILITY 'ADDRESS , ATANK <br /> TANK SIZE l��JC� FUEL TYPE ,� C 0 D�__V <br /> � p4C I I <br /> 11. GENERAL SITE HISTORY r++ <br /> Is permit current? Yes No Permit # - Facility Status Code99 Doc.Soit/GW Cont Yes No <br /> Nuer of Tanks at facility Age of Tanks(if available) �y PS Type of Tank Steel Fbrgl Sngl Duel <br /> rb <br /> III. TANK HISTORY 14 <br /> Was Tank tested? Yes I V�Nol Failed precis on test 7 Yes No If yes, give date(s) <br /> Was a repair mode to the tank system? Yes No If yes, what was repaired? ,P�eilLe- � a� /15 <br /> was repair done under inspection? Yes No Vere soil samples analyzed? Yes No VIBTXEI TPH-G TPH-D Pb/EDB <br /> Type of failure/discharge catastrophic long-term leakage overfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSP CT ON REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes N Depth to Ground water 6 Ref/Year ;78,(, Averagerismt <br /> pitation A= 14 10-25 <br /> On-Site Well(s) Yes No Number 6 Type Irr Dom Pub <br /> S SS Score <br /> Distance to wells) tram Tank ft; ft; ft C 1C5 pts <br /> 0 i0 if <br /> R cn R condition <br /> V. Site Feature - leaching Potential Analysis E iE Is met <br /> Minimum Depth to groundwater fromthe Soil Sample (feet) fr.I- n.��pl >100 51-100 D 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown Present <br /> Average Annual Precipitation (inches) xxxxm <10 9 10-25 XXxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) None Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby welts. At Least More than <br /> xxxxxx None /,J�- one l�/ 2) one <br /> G� TOTALS»>TOTAL POINTS + I + ' ✓� <br /> Sample Resul T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> $�N D• E=N•D• BT X E B T X E <br /> T,Al,D• x� ,Dls M IMIAI 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 /> 2 IM <br /> %I ALLOWABLE TPH LEVELS (PPM) DIESEL 10,000 1000 100 <br /> m TPN <br /> FOOTNOTES: •••It doc ted soil ardor 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 depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> It precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTXSE are not applicable at a TPH concentration of 10 ppm (Basaline)�,,or,„1,0,0��p�pm (diesel). <br /> VI. STAFF RECCMMENDATION/CONCLUSION ' All r—P "�'"Q�r{�"`— z Al. J), <br /> 1. Are BTX 8 E or TPN Concentrati > Allowable Levels *Yes No -/II�L�` "`�" j I1�A <br /> 2. Recommend Site Closure Yes No •It Yes, Rafer to Site Mitig tion for Evaluation 'r UY 1/nw <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR -- <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 /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />