Laserfiche WebLink
SAN JOAQU` CCUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAATH DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> qME OF FACILITY EEPS CODE <br /> ODRESS S 3(/ - / l per. ANK ID # <br /> TANK SI2E IFUEL TYPE <br /> If. GENERAL SITE HISTORY ** <br /> Is permit current? ks o ermit # aciLity Status Code a.Soil/GW Cont es !o <br /> umber of Tanks at facility Be of Tanks(if available) IType oFT ank teal Fbrgl I ngl Dual <br /> Ill. TANK HISTORY <br /> ns Tank tested? es INO <br /> ailed precision test ? Ls o If yes, give date(s) <br /> es a repair made to the tank system? es No f yes, what was repaired? <br /> ns repair done under inspection? es o ere soil samples analyzed? Fes to I TXE PH-G I PH-D I b/EDD <br /> ype of failure/discharge atastrophic long-term leakage verfill nknown ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oft Samples Received as o epth to Ground Water of/Year verage Annual Precipitation = 4 10-25 <br /> )n-Site Wells) ITas o I umber 8 Type irr I om I ub <br /> S Score 5 Score 5 Score <br /> istance 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 conditi an R condition <br /> Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1.100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10.25 KXXxxxx 26-40\2 <br /> an•Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> Inique site features: Recharge area, coarse soil, nearby welts. At least 4ore than <br /> xxxxx None one //�� oonnne <br /> COLUMN TOTALS>»TOTAL POINTS F • �(l 3(� <br /> Sample Result: (S T1 X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or Less <br /> B T % E B T X E <br /> '1 I <br /> MAXIMUM ALLOWABLE B-T•X-E LEVELS (PPM) 1 50 50 50 .3 .3 i. 1. NA\3 <br /> Sample Result: ASOLINE 1000 100 10 <br /> 17 <br /> nDLI/,V AXLMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH �� IESEL. 10,000 1000 100 <br /> FOOTNOTES: ***If documented soft and/or ground water contamination is present, do not 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 1 d� <br /> 1, Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure as 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 JO <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> .VALUATOR ASSa <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />