Laserfiche WebLink
SAN JOAQUIN C `Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE! DIVISION <br /> �• `a8T WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AHE OF FACILITY / WEEPS CODE <br /> DRESS C /�, ANK ID s - <br /> ANK SIZE 11EL TYDE v <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? es o emit # - aciLity Status Code oc.Soi L/GW Cont eS o <br /> urber of Tanks at facility ge of Tanks(if available) ype of Tank Leel Fbrgl ngl Dual <br /> 111. TANK HISTORY <br /> as Tank tested7 es a ailed precision test 7 es o if yes, give date(s) <br /> Jas a repair made to the tank system? es No f yes, what was repaired? <br /> Jas repair done under inspection? es No ere soil samples analyzew es o I TXE I PH-G I Ir <br /> PH•D b/EDB <br /> y; Of failure/discharge atastrophie Lang-term Leakage verf ill Hawn 1 10 <br /> cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es o epth to Ground Water ;- of/Year �j ;d-(o verage Annual Precipitation z 4 0-25 <br /> -Site Wells) es o umber & Type Irr am <br /> S Score S core S core <br /> istance to Wells) frac Tank ft; ft; ft C 0 pts C pts C pts <br /> 0 if 0 if 0 if <br /> R condition R ondition R ondi tion <br /> J. Site Feature . Leeching Potential Are lysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sanple (feet)ZM ISI >100 1-100 25-501 <br /> Fractures in subsurface (appLi es to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) xxxx <10 9 10-25 x 26-40L <br /> Ian-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) More Unknown resent <br /> ique site features: Recharge area, coarse soil, nearby wells. At least 4ore than <br /> None one one <br /> COLUMN TOTALS>»TOTAL POINTS <br /> ample Result: (B 1 X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or Less <br /> �0ff �1�� 8 T X E 8 T E <br /> 1 NMI" ALLOWABLE S-T-%-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. M 3 <br /> Sample Result: `���11 LINE 1000 100 10 <br /> 1 IMUN ALLOWABLE TPN LEVELS (PPM) <br /> l TVN IESEL 10,000 1000 100 <br /> FOOTNOTES: •"if documented soil and/or ground water contamination is present, do riot complete the Leaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> \11 If depth is > 5 ft. and < 25 ft., scare 0 points. If depth c5 ft., do not use table. <br /> If precipitation is > 40 inches, score 0 points. <br /> L Levels for 8TX&F are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION TO Ippm <br /> �'a <br /> 1. Are 8TX & E or TPN Concentrations > ALL owable Levels Yes I II01 <br /> 2. Recoaaavd Site Closure es o If Yes, Refer to Site Mitigation for Evaluation �lpr <br /> VII. REVIEW EVALUATION . TO BE COMPLETED BY A SUPERVISOR/SENIOR rn <br /> ONCUR WITH STAFF RECDMMEHDATION FOR CLOSURE ES EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERREDATE CLOSURE LETTER MAILED <br /> AME DF _,syr <br /> -2-1 <br /> Cj <br /> t <br /> EH 23 30 (UGTWKSHT)\5/90 <br />