Laserfiche WebLink
SAN JOAQUIN QTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE,�, DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> (NAME Of FACILITY C SWEEPS CooE a-3 <br /> 'ADDRESS , 1 •J S TANK ID # - <br /> TANK SIZE /A 0or FUEL TYPE lig-- 1 <br /> II. GENERAL SITE HISTORY <br /> ��w <br /> Is permit current? Yes No Permit # - Facility Status Code Q Doc.Soil/GW Cont Yes No <br /> Number of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test o Yes X No If yes, give date(s) <br /> Was a repair made to the tank system? Yes Mo If yes, what was repaired?I Zti,ek rC.�'4!c <br /> Was repair done under inspection? Yes No Ix <br /> Were soil samples analyzed? Yes No BTXE TPH-GI TPH-D Pb/EDB <br /> Type of failure/discharge catastrophic long-term Leakage overfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Ground Water 5 Ref/Year Average Annual Precipitation A= 14 .10-25 <br /> On-Site Well(s) Yes No Number 8 Type Irr Dom Pub <br /> 5 Score S Score S Score <br /> Distance to WeIL(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 E is met E is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet) >100 51-100 5 - 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) O None Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) l None Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At Least More than <br /> xxxxxx None ane one <br /> COLUMN TOTALS>»TOTAL POINTS <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or Less <br /> B T X Ee T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1- NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH DIESEL 10,000 1000 100 <br /> FOOTNOTES: *'*If documented soil 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 <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels *Yes No <br /> 2. Reco miend Site Closure)Yes I INoI rrFte 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 YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />