Laserfiche WebLink
SAN JOAQUIN PUBLIC HEALTH SERVICES/ENVIRONMENTAL MEAyyJIVISION <br /> 1• UGST WORKSHEET FOR SITE CLOSURE EVALUATIONGATE `3 <br /> to <br /> NAME OF FACILITY N v e �.� SWEEPS CODE <br /> ;ADDRESS 2(150 �, �� [)JD S TANK ID <br /> TANK 512E 'L FUEL TYPE PYn8vv\ <br /> 3� - oil S6b`7 <br /> 11. GENERAL SITE HISTORY <br /> ,Is permit current? YesNo Permit # - Facility Status Code DOC.SoiL/GW Cont Yes No I '1T <br /> lNuober of Tanks at facility .�, 2 Age of Tanks(if available) 0 I b Type of Tank Steel Fbrgl Sngl Dual <br /> III. TANK HISTORY Waol) C0n Ctok, *-(a <br /> ,Was Tank tested? Yes No Failed precision test ? Yes No If yes, give date(s) <br /> 'Was a repair made to the tank system? Yes No X If yes, what was repaired? <br /> Was repair done under inspection? Yes NoIx Were soil samples am Lyzed? Yesix I No BTXE x TPH-G xi TPH-D Pb/ED8 <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 L y Ref/Year rI ;zi( Average Annual Precipitation A- 14 10-25 <br /> On-Site WeLL(S) Yes No Number 8 Type Irr Dom Pub <br /> 5 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 it 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 Iq I Unknown Present <br /> lAverage Annual Precipitation (inches) xxxxxx <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 wells. At Leastl More than <br /> xxxxxx None one one <br /> I. <br /> COLUMN TOTALS>>>TOTAL POINTS + + _ l <br /> ;Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pis or more 41 - 48 pts 40 pts or less <br /> NDB T X E 8 T X E <br /> 1v MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 5050 .3 .3 1. 1. NA\3 <br /> ,Sampte Result: GASOLINE 1000 100 10 <br /> MAXINUM ALLOWABLE TPH LEVELS (PPM) <br /> OLD TPH D DIESEL 10,000 1000 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 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. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPH Concentrations > Attowable Levels *Yes )< No <br /> i <br /> 2. Recommend Site Closure Yes No If Yes, Refer to Site Mitigation for Evaluation <br /> V'I. 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 / /d DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />