Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL h`ALTH DIVISION <br /> I. 'IGST WOOORR/KSHEET FOR SITE CLOSURE EVALUATION DATE ]!� <br /> NAME OF FACILITY j/eV�.t7 �7 / _ iWEEPS CODE 6 g' <br /> ADDRESS t.._v�/� S/�� W, 6r_ / [.�fJ'�. �Z q TANK ID # / Z C�-y <br /> TANK SIZE '� FUEL TYPE � /J , / <br /> 11. GENE AL SITE HISTORY <br /> Is permit current? Yes No Permit # - Facility Status Code d Doc.SOEl Coni Yes No <br /> Number of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual <br /> III. TANK HISTORY <br /> Was Tank testedl Yes No Failed precision test 7 Yes No If yes, give date(s) <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? <br /> Was repair done under inspection? Yes No Were soil samples analyzed? Yes No BTXE 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 Ref/Year Average at Precipitation A- 14 10-25 <br /> On-Site Well(s) Yes No Number 8 Type Irr Dan Pub <br /> S Score S Score 5 Score <br /> Distance to well 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 /> Minim Depth to groundwater from the Soil Saaple (feet) >100 51-100 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 /> 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 least More than <br /> xxxxxx None / one one <br /> COLUMN TOTALS»>TOTAL POINTS / j + <br /> Sample� Result:( TT X OR E) RANGE OF TOTAL POINTS 49 pts or mare 41 - 48 pts 40 pts or less i✓a#c * 1 <br /> B r x E B T x E <br /> MAXIMUM ALLOWABLE B-T-x-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Fampte Rg6ult:5(A--7' GASOLINE 1000 100 10 <br /> iVLCG' MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> DIESEL 10,000 1000 100 <br /> FOOTNOTE$: Z *'*If documented soil and/or ground water contamination is present, do not coaplete the teaching 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 /> 26 \3 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> XVI! REC0MMENDATION/CONCLUSION / <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels 'Yes No <br /> 2. Recommend Site Closure Yes No If Yes, Refer to Site Mitigation for Evaluation <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 SURE LETTER NAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />