Laserfiche WebLink
SAN JOAQUIN COU48LIC HEALTH SERVICES/ENVIRONMENTAL HEALT: SION <br /> UGSY WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NATE OF FACILtTY SWEEPS CODE Z <br /> \I (TANK ID 0 <br /> ) <br /> TANK S12E FUEL TYPE <br /> GENERAL SITE HISTORY <br /> *rfr <br /> is permit current? Yes Noi ,Permit I Facility Status Code Doc.SoiL/GW Cont Yes) INo <br /> Number of Tanks at facility Age of Tanks(if available) f Type of Tank Steel Fbrgl) ISngll Dual) <br />'' :III. TAW HISTORY <br /> Was Tank tested? Yes NoI Failed precision test ? Yesl give date(s) <br /> Ws a repair made to the tank system? Yes{ V�No If yes, what was repaired?I <br /> s � n <br /> was repair done under inspection? Yes NoI Were soil samples analyzed? Yes No� BTXE TPH-G, ITP14-01 Pb/EDB <br /> Type of failure/discharge) Icatastrophic tong-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! ,Ref/Year Average Annual Precipitation A=114. i10-25 <br /> 1 <br /> On-Site Well(s)IYes NoI (Number & Typel ilrr (Dom )Pub <br /> I S Score S Score S Score <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 condition R condition R condition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met = his met <br /> Minimum Depth to groundwater from the Soil Sample (feet)4 0 I >100 I51-100 M ! 25-50\1 <br /> i <br /> Fractures in subsurface (applies to foothills or mountain areas) None I Unknown ;Present <br /> !Average Annual Precipitation (inches) xxxxxx{ <10 9 1 10-25 Ixxxxxxx! 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) None Unknown I Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. I At Least) More than <br /> xxxxxx! None one II one <br /> i <br /> COLUMN TOTALS>>>TOTAL POINTS <br /> (Samote Result: (B TT X OR E)r' RANGE OF TOTAL POINTS 49 pts or more 48 pts W pts or less <br /> E = i(J0-30i B T X E B D MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50I 50I 50 .3 JT <br /> ..3 XR, 1. NA\3 <br /> Sa=te Resuk GASOLINE 1000 r 100 10 <br /> rK 1. 1w MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPHD DIESEL 10,000 10001 ' " 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do t comple the leaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for s 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 BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel)- <br /> VI. STAFF RECOMMENDATION/CONCLUSION ` <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels I*Yes XI <br /> No <br /> 2. Recommend Site Closure Yes No if Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/ IOR " <br /> CCNCUR WITH STAFF RECOMMENDATION FOR CLOSURE IYES NO! REFERRED TO SITE MITIGATION FOR EVALUATION No NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR, <br /> EN 23 80 (UGTWKSHT)\5/90 <br /> NOW <br />