Laserfiche WebLink
SAN JOAQUIN C' f PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL DIVISION <br /> 1. `6T WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY (SWEEPS CODE( J ji <br /> (ADDRESS( TANK IDit 3 --R5AS—� D <br /> TANK SI2EI A4 DOD (FUEL TYPE (SA k) VE <br /> :I. GENERAL SITE HISTORY <br /> >sr <br /> [s permit current? Yes No ixPermit - Facility Status Cade Dad.Soil/GW Cant IYes No <br /> �Number of Tanks at facility Age of Tanks(if available)( L,,,k Type of Tank l Steel Fbrgl NSngt OWL <br /> 111. TANK HISTORY <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 Na xIf yes, what was repaired? <br /> Was repair done under inspection? Yes B <br /> No Were sail samples analyzed? Yes No TXEI ITPH-G TPH-0 Pb/EDB <br /> Type of failure/discharge) catastrophic hong-term leakage Ioverfill unknown Iother: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Sail Samples Received Yes No Depth to Ground Water /1Q (Ref/Year (3 Average Annual Precipitation A= 14 10-25 <br /> On-Site WeLL(s) Yesl No Nunber & Type Irr Dom Puol <br /> S Scare 5 Score S Score <br /> Distance co Wel l(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> O if 0 if 0 if <br /> R condition R condition R condition <br /> V. Site Feature - Leaching Potential Analysis IE is met c is met E is met <br /> Minimum Depth to groundwater from the Sail Sample (feet) J�D— / �- ( >100 1 X51-100 I 125-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) ' V I None I Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx <10 1 9 110-25 Ixxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> iof leachate (i.e., septic systems, water wells, ponds) None Unknown Present <br /> Unique site features: Recharge area, coarse sail, nearby wells. At Least More than <br /> xzxxxx more / one [/•Orme <br /> . COLUMN TOTALS»>TOTAL POINTS 1 D i (D ' D - •]'(Q <br /> Samole Result: (8 T X OR c) RANGE OF TOTAL POINTS 49 pis or more 41 - 4B pts 40 Pis or less <br /> '°dam g T % E 3 T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) tl 50 50 50 .3 .3 1. 1. NA\3 <br /> TanAlI RE. <br /> E. <br /> ,P DO GASOLINE 1000 100 10 <br /> f( MAXIMAL ALLOWABLE TPH LEVELS (PPM) <br /> 1'11 I W L6SD TPH D DIESEL 10,000 1000 100 <br /> FOOTNOTES: —If documented sail and/or ground water contamination is present, do amQ etc a 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 ca5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for 8TX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels 'Yes No <br /> 2. Recommend Site Closure Yes No f.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 I YESI NOI (REFERRED TO SITE MITIGATION FOR EVALUATION YES( NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EN 23 80 (UGTWKSHT)\5/90 <br />