Laserfiche WebLink
SAN JOAQUIN CL,...IY PUBLIC HEALTH SERVICES/ENVIRONMENTAL NEA, J[VISION <br />I UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE „; — O <br />NAME OF FACILITY <br />S SWEEPS CODE( 3 / O <br />ADDRESS C /`/ (TANK ID TI 3 D EZ— <br />TANK SIZE /A (FUEL TYPE <br />II. GENERAL SITE HISTORY *** <br />Is permit current? Yes No `Permit $ - (Facility Status Code Doc.SoiL/GW Cont Yesl No <br />Number of Tanks at facility <br />Age of 7anks(if available)( O Type of TanklSteel IFbrgl Sngl) Dual <br />I I I. TANK HISTORY Std & l T T <br />Was Tank tested? Yes No�FaiL�edprecision test ? Yes No If yes, give date(s) 3 / / ?C; <br />Was a repair made to the tank system? Yes Nol If yes, what was repaired?i <br />lWas repair done under inspection? Yes Nal Were soil samples analyzed? Yes Nol BTXE ITPH-G (TPH-0I IPb/EDB( <br />!Type of failure/discharge) catastrophic Ilong-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 ; <br />Average Annual PrecipitationlA=`14 10-25 <br />On -Site Wells) Yes No Number & Type Irrl (Dom) (Pub S Score S Score S Score <br />ft C 10 pts C pts C <br />Distance to Well if 0 s) from Tank ft; ft; i pts <br />0 if 0 if <br />R condition R condition R condition <br />v. Site Feature - Leaching Potentia{ Analysis <br />E is met � is met E is met <br />Minimum Depth to groundwater from the Soil Sample (fees) �O — <br />>100 151-100 I l 25-50\1 <br />Fractures in subsurface (applies to foothills or mountain areas) <br />I None I I Unknown (Present <br />Average Annual Precipitation (inches) xxxxxx <10 I 9 10'25 Ixxxxxxxl 26-40\2 <br />1 <br />Man-made conduits which increase vertical migration I None I I Unknown (Present <br />of leachate (i.e., septic systems, water wells, ponds) <br />At least) More than <br />Unique site features: Recharge area, coarse soil, nearby wells. xxxxxxl More one one <br />COLUMN TOTALS>>>TOTAL POINTS I <br />RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or Less <br />Sample Result: (B T X OR E) <br />B T X E 3 T X I E <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) 1 50 50 50 I .3 I.3 11.E 1. NA\3 <br />S ` l R suit: GASOLINE 1000 100 10 <br />T� !,L MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br />b_I 1 � <br />DIESEL 10,000 1000 100 <br />TPH <br />FOOTNOTES: <br />***If documented soil and/or ground water contamination is present, do nole a 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., scare 0 points. If depth <=5 ft., do not use table. <br />\2 If precipitation is > 40 inches, score 0 points. p� (gasoline) or 100 ppm (diesel). <br />\3 Levels for BTX&E are not applicable at a TPH concentration of 10 <br />VI. STAFF RECOMMENDATION/CONCLUSION C A VM <br />1. Are BTX & E or TPH Concentrations > Allowable levels *Yes No <br />2. Recommend Site ClosurelYes INo *If Yes, Refer to Site Mitigation for Evaluation(y , j" 'j�� L at <br />7 13 "A R-0 � <br />VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR i4 <br />DMr� <br />CONCUR WITH STAFF RECOMMENDATION FOR CLOSUREIYESI INO) IREFERRED TO SITE MITIGATION FOR EVALUATION IYE NOI I �/ <br />DATE REFERRED (DATE CLOSURE LETTER MAILED( <br />NAME OF <br />EVALUATOR <br />EH 23 30 (UGTWKSHT)\5/90 J ' 4 <br />q. <br />