Laserfiche WebLink
SAN JOAQUIN COON AMLIC HEALTH SERVICES/EVVIRONMEVTAL REALTY " ION DATE( <br /> UGS KSXEET FCR SITE CLOSURE EVALUATION <br /> SWEEPS CORE 0( / <br /> NAME OF Nlj� <br /> TY <br /> TANK ID itNa <br /> �3C� <br /> ADDRESS �TANK SIZ � Q FUEL TYPEI � i 1 P0 <br /> 1I. GENERAL SITE HiSTCRY ' <br /> Is permit current? Yes No Permit 9 - Facility Status Code Doc.Soil/Gid Cant Yes No <br /> Number of Tanks at facility <br /> Age of Tanks(if avaiLable)- Type of Tank Steel Fbrgi Sngl Dual <br /> III. TANK HISTORY <br /> Wassted? Yes No ed precision test ? Yes Na If yes, give <br /> dates) <br /> was a repair made to the tank ��Fai <br /> l Yes No� if yes, <br /> what was repaired? <br /> was repair done under inspection? Yes �Noi were soil samples anaLYzed? Yes Na BTXE� TPN-GI ITPH-D IPb/E08i <br /> Type of failure/discharge catastraphic long-term Ieakage Overfillunknown# other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Satl samples Received�Yes No Depth to Ground water Ref/Year , <br /> Average Annual Precipitation A=}14 10-25 <br /> On-Site wellCs) Yes INo Number & iypej Irr lDam S Score S Score S Scare <br /> ft C <br /> Distance to wett(s) from Tank ft; ft; ipts C 5 pts <br /> f pts C 0 i <br /> 0 if 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 /> /� >IGO I51-100 25-50\1 <br /> Minimum Depth to groundwater from the Soil Sample (feet? 7'� <br /> Fractures in subsurface (applies to foothills or mountain areas) <br /> 4 momI � Unknown I IPres+ent <br /> xu=xl <10 4 I 10-25 xx:ocxzX Z5-40\2 <br /> Average Annual Precipitation (inches) j <br /> lMan-Made conduits which increase vertical migration I Yore I Unknown I (Present <br /> of leachate (i.e., septic systems, water we(ls, ponds) <br /> Recharge area, coarse sailAt least More than <br /> Unique site features: , nearby wells- xxxxxx� Norte !l am one <br /> 4 <br /> COLUMN TOTALS»'TOTAL POINTS <br /> } I } <br /> Sample ResuLt: (S T X OR E) <br /> RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> 'h6'r�1," le- = A—rX-9 AA) a T x E a JT x <br /> = IV; L']�^i V / MAXIMUM ALLOWABLE a-T-x-E LEVELS (PPM) 1 50 50 50 .3 ,3 1. 1. <br /> Sample Result: _ I GASOLINE 1000 100 � I 10 <br /> cf✓�}c�Y 2, / ice+ wq'IK- MAXIMUM ALLOWABLE TPdi LEVELS (PPM) 10,000 1000 100 <br /> TPN DIESEL <br /> FOOTNOTES: —If documented soil and/ar ground water contamination is present, do not complete the Leatng potential <br /> F = j [ �+ analysis. (i.e., site is currently on UGT Contamination List for sail or ground water.) <br /> H 1� \1 if depth is > 5 ft. and < 25 ft., scare 0 points- If depth <r5 ft., da not use table. <br /> © \2 If precipitation is > 411 inches, score 0 points- <br /> r 1 U Com'\3 Levels for BTX&E are not applicable at a TPN concentration of i0 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION `S-t �\ (�! 1_`� <br /> 1. Are 3TX & E or TPN Concentrations > ALLowable Levels *Yes No 1 <br /> 2. Recommend site Closure iYes l No if Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO 3E COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE�YESJ INOI REFERRED TO SITE MITIGATION FOR EVALUATIONJY �NO <br /> DATE REFERRED / / (DATE CLOSURE LETTER MAIL ? ! 1 <br /> NAME OF <br /> EVALUATOR <br /> EH 23 30 (UGTWKSHT)\5/90 <br />