Laserfiche WebLink
SAN JOAQUIN C PUBLIC HEALTH SERVICES/ENVIRONMENTAL NEA. DI Vt$ION <br /> !. GST WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY ;gnL,`i U 'T��I,N I11 �,�.�-}-,Qn SWEEPS CODE GSo3 <br /> ADDRESS )c 'jc �" �� c.lGUc+�`S S Q; ✓ TANK ID 9 -�c� - So S- <br /> TANK SIZE I FUEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? Yes No I VIFermit # - Facility Status Code �oil/GW Cont Yes No <br /> Number of Tanks at facility Age of Tanks(if available) lc. Type of Tank Steel Fbrgl Sngl Dual Ll <br /> Ill. 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 If yes, what was repaired? <br /> Was repair done under inspection? Yes No Were soil samples ana lyxedl 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 L1U Ref/Year SS-b ; Average Annual Precipitation A= 14 10-25 <br /> On-Site WeIL(s) Yes Noj , Number & Type Irr Dom Pub <br /> S Scare 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 Analysis E is met E is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (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 /> sof leachate (i.e., septic systems, water wells, ponds) None Unkmwin Present <br /> Unique site features: Recharge area] coarse soil, nearby wells. At least More than <br /> �GA4k0"_4-5 / 7 c % XXxxxx None one one <br /> � C <br /> COLUMN TOTALS>>>TOTAL POINTS L i + �9 + <br /> Sample Result: (S T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> Nn B T 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 /> Sample Result: GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH DIESEL 10,000 1000 100 <br /> FOOTNOTES: "'If documented soil and/or ground water contamination is present, do not coaplete the Leaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or growl 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 BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAF° 2ECOMMENDATION/CONCLUSION <br /> i <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 <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 `-�jL�L./`4�•�—�' <br /> EH 23 80 (UGTWKSHT)\5/90 <br />