Laserfiche WebLink
SAN JOAWIN C PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL VISION <br /> I. t WORKSHEET FOR SITE CLOSURE EVALUATION ATE �- 1 <br /> AME OF FACILITY2i.(_,f.fn.(in..Lt_ r21✓ ^�,��� WEEPS CODE �!/ p <br /> ORE'S S�d �.1.C7'Cc•Yti l/ ANK ID # <br /> TANK SIZE OO(� UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> IS permit CUrf enL? e5 O efmiC IF <br /> aC1L1 Cy Status Code OC.SOI I/GW Cont e5 0 <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tank teal Fbrgl ngl Dual <br /> 111. TANK HISTORY <br /> Pas Tank tested? as o ailed precision test ? es o If yes, give date(s) <br /> as a repair made to the tank system? 1Yes No f yes, what was repaired7 <br /> as repair done under inspection? es o ere soil samples analyzed? 1Y <br /> es I TXE I PH'G I PH'0 I b/ED8 <br /> ype of failure/discharge atastrophit long-term leakage verfill mown 1 10 <br /> cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received as o epth to Ground Water of/Year F7/ verage Annual Precipitation k= 4 0-25 <br /> n-Site WeLI(s) 1Yes o umber 8 Type irr an ub <br /> S Score S Score 5 3core <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 ondition R Condition R ordition <br /> V. Site Feature . Leaching Potential Analysis E is met E is met -c is met <br /> inimum Depth to groundwater from the SoiL Sample (feet) >100 1.100 ,C 25-5011 <br /> Fractures in subsurface (applies to foothills or maintain areas) None Unknown resent <br /> verage Annual Precipitation (inches) uxxxx <10 9 10-25 i=xxxx 26-4oL <br /> Ian-Made conduits which increase vertical migration <br /> Df leachate (i.e., septic systems, water wells, ponds) More Unknown S resent <br /> pique site features: Recharge area, coarse soil, nearby wells. At least ore than <br /> xxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS + 1�! + <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less. <br /> T % E B T X E <br /> MAXIML24 ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA13 <br /> ample Result: SOLINE 1000 100 10 <br /> G _ _ - IMUM ALLOWABLE TPH LEVELS (PPM) <br /> L. LYPH h, IESEL 10,000 1000 100 <br /> FOOTNOTES: *"If documented soil and/or ground water contamination is present, do not complete the leaching potential <br /> are lysis. (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 TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION ' <br /> 1. Are BTX 8 E or TPM Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure es I% o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION . TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES O <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />