Laserfiche WebLink
OF FACILITY <br />SAN JOAQUIN COUNTY/ PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL%d61V15)ON DATE <br />UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br />SWEEPS CODE <br />TANK ID # 2 G " <br />(TANK SIZEI ( S11L\Qi� FUEL TYPEI4j±�_ <br />*** <br />11. GENERAL SITE HISTORY <br />Facility Status Code <br />Doc.Soil/GW <br />Cont Yes No <br />is permit current? Yes No Permit # ' <br />Tank <br />Steel <br />Fbrgl <br />Sngl Dual <br />Age of Tanks(if available) Type of <br />Number of Tanks at facility <br />, <br />III. TANK HISTORY <br />No If yes, give date(s) <br />e <br />Was Tank tested? Yes No Failed precision test ? Yes <br />repair made to the tank systYes No if yes, what; was repaired? <br />Wem? <br />Was a <br />samples analyzed? Yes No <br />BTXE <br />TPH-1 <br />TPH-D Pb/EDB <br />Was repair done under inspection? as No Were soil <br />long-term Leakage overfill unknown <br />other: <br />Type of failure/discharge catastrophic <br />DATA FOR LEACHING POTENTIAL <br />ANALYSIS) <br />_ <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT <br />Annual <br />Precipitation <br />A= 14 10-25 <br />No Depth to Ground Water Ref/Year , Average <br />Soil Samples Received Yes <br />Irr Dom Pub <br />On -Site Wells) Yes No Number 8 Type S Score <br />S <br />Scare <br />S Score <br />ft; ft C 10 pts <br />CO <br />9fpts <br />CO 5fpts <br />ft; <br />Distance to Wells) from Tank 0 if <br />R <br />condition <br />R condition <br />R condition <br />E is met <br />E <br />is met <br />E is met <br />V. Site Feature - Leaching Potential Analysis <br />)100 <br />C1 <br />51-1001 <br />125-50\1 <br />Minimum Depth to groundwater from the Soil Sample (feet) <br />in (applies to foothills or mountain areas) None <br />Unknown <br />Present <br />Fractures subsurface <br /><10 <br />9 <br />10-25 <br />xxxxxxx 26-40\2 <br />xxxxxx <br />Average Annual Precipitation (inches) <br />Man -Made conduits which increase vertical migration I' None <br />Unknown <br />Present <br />of leachate (i.e., septic systems, water wells, ponds) l <br />More than <br />Unique site features: Recharge area, coarse soil, nearby wells- xxxxxx None <br />^, <br />t� <br />At least <br />one <br />one <br />COLUMN TOTALS»)TOTAL POINTS <br />2� Z? + b = rl <br />Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 7 48 pts 40 pts or less <br />8 T X E 8 T X E <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br />GASOLINE 1000 100 10 <br />Sample Result: MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br />DIESEL 10,000 1000 100 <br />TPH <br />***If documented soil and/or ground water contamination is present, do not <br />FOOTNOTES: 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 > Allowable LevelsTtoSIte <br />No <br />2. Recomnerd Site Closure Yes No *If Yes, RefMitigatio�flrEvaLu�atin <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 MAILED <br />NAME d\ I. A .nn_ nn n.` —�\n <br />EH 23 80 (UGTWKSHT)\5/90 <br />