INSTALL 2018 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT UST WORKSHEET FOR SITE CLOSURE EVALUATION I. FACILITYITANK INFORMATION DATE: SITE/FACILITY NAME: STATUS CODE: ADDRESS: CITY: FA#: PR#: TANK# 39 TANK SIZE: FUEL TYPE: II. GENERAL SITE HISTORY Is Permit Current? ❑ Yes ❑ No ❑ NA Documented Soil/GW Contamination?'** ❑ Yes ❑ No Number of Tanks at Facility Age of Tanks(if available) Type of Tank❑Steel ❑Fiberglass ❑Single ❑Dual III. TANK HISTORY Was Tank Tested? ❑Yes ❑No ❑ NA Failed Testing? ❑Yes ❑ No ❑ NA If Yes, Provide Dates: Was Tank System Repaired?❑Yes ❑ No ❑ NA If Yes, Describe Repair: Was Repair Done Under Permit? ❑Yes❑ No❑ NA Were Soil Samples Analyzed? ❑Yes ❑ No ❑BTEX❑TPH-G ❑TPH-D ❑ LEAD❑ EDB ❑ OTHER ❑OXYGENATES Type of Failure/Discharge: ❑ Catastrophic ❑ Long-term Leak ❑ Overfill ❑ Unknown ❑ Other IV. REMOVAL HISTORY(Attach File) Soil Samples Received? L3 Yes LJ No Seasonal High Depth to GW ft bgs Year/Reference Onsite and/or Nearby Well(s)? ❑Yes ❑ No Ll Irrigation: # Distance to Tank ft � Score 10 C Score 9 C ❑Domestic:# Distance to Tank ft 0 points if 0 points if 0 Score 5 points if ❑ Public: # Distance to Tank ft R condition is R condition is R condition is met V. SITE FEATURE—LEACHING POTENTIAL ANALYSIS E met E met E Minimum Depth to Groundwater from Soil Sample(feet) >100 51 —100 25-501 Fractures in Subsurface(applies to foothill or mountain areas) None Unknown Present Average Annual Precipitation(14 inches for SJC area) -------- <10 9 10-25 -------- 26-402 Man-Made Conduits which Increase Vertical Migration None Unknown Present i.e.septics stems,water wells, ponds) Unique Site Features: Recharge Area, Coarse Soil(coarse sands, None At Least One More Than One gravels),nearby wells Column Totals Total Points + + - Sample Results for BTEX: Range of Total Points 49 Points or More 41 —48 Points 40 Points or Less B T Maximum Allowable BTEX B T E X B T E X 3 E Levels(ppm) 1.0 50 50 50 0.3 0.3 0 1.0 N/A X Sample Results for TPH: Maximum Gasoline 1,000 100 10 Allowable TPH Levels m Diesel 10,000 1,000 100 Footnotes: *'*If documented soil and/or groundwater contamination is present,do not complete leaching potential analysis(i.e.site is already on the contamination list). If depth is>5 feet and<25 feet,score 0 points. If depth is-5 feet,do not use table. 2 If precipitation is>40 inches,score 0 points. 3 Levels for BTEX are not applicable at a concentration of 10 ppm for TPH—Gasoline or 100 ppm for TPH-Diesel. VI. STAFF RECOMMENDATION/REFERRAL/REVIEW 1. Are BTEX or TPH Concentrations>Allowable Levels? ❑Yes ❑ No 2. If No, Is Site Closure Recommended? ❑Yes ❑ No Completed By: Date Referred to Site Mitigation Unit for Final Actiont Reviewed By: Concur with Staff Recommendation ❑Yes ❑ No Date Closure Letter Mailed tAll Cases are Referred to Site Mitigation for Final Action EH 23-0080(Rev 11/14/08)