Laserfiche WebLink
SAN JOAOUIN-,utJNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H ;A,H DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE I.3 <br /> AME OF FACILITY r C,�5 WEEPS CODE 2 C)�1 S <br /> DDRESS Q z4 3 jF �� <br /> J G TANK ID # <br /> ANK SIZE UEL TYPE <br /> 11. GENERAL SITE HISTORY �- <br /> Is permit current? as o ermit # acitity Status Code 5 C oc.Soil/GW Con es Jo <br /> umber of Tanks at facility ge of Tanks(if available) ((o ype of Tank teel Fbrgi 17n9l Dual <br /> III. TANK HISTORY 11%5tALU 1250fs(- <br /> IF re-wwv <br /> as Tank tested? es o ailed precision test ? es IN01 If yes, give date(s) <br /> as a repair made to the tank system? 1Yes No f yes, what was repaired? <br /> is repair done under inspection? es o ere soil samples analyzed? es to TXE PH-G PH-D b/EDD <br /> ype of failure/dischargeatastrophic long term leakage verfill nknown ther: <br /> 10 <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es o epth to Ground Water of/Year verage Annual Precipitation = 4 10-25 <br /> n-Site Well(s) es 4umber & Type Irr I om ub <br /> S core S core S core <br /> istance to Well(s) from Tank ft; ft; ft C 0 pts C pts C pis <br /> 0 if 0 if 0 f <br /> R ondition R ondition R ondition <br /> Site Feature - leaching Potential Analysis E is met E is met E s met <br /> ---------------- <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) xxxxx <10 9 10-25 xxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> lnique site features: Recharge area, coarse soil, nearby wells. At least lore than <br /> xxxxx None one one <br /> COLUMN TCTALS»>TOTAL POINTS + + <br /> ample Result: (B T X OR E) / RANGE OF TOTAL POINTS 9 pts or more 41 48 pis 40 pts or less <br /> r pr- <br /> o - NO 3opp <br /> B4.21•l�S� <br /> _ NO �P�" Btl <br /> TE B TX E <br /> T" AID SoP .» MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 150 50 .3 .3 1. 1. NA\3 <br /> 'ample Result: GASOLINE 1000 100 10 <br /> PPrvl TPH, ..o <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> N�ayIESEL 10,000 1000 100 <br /> TNOTES: ***If documented soil and/or ground water contamination is present, do not complete the teaching 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 BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION 1,1,1 Tri r-kta--or-t %c_4,%.G 507 <br /> 1. Are BTX & E or TPH Concentrations > Allowable 190 1 h ap^a r p v✓ ct S <br /> 2. Recommend Site Closure es o if Yes, Refer to Site Mitigation for Evaluationl�l'l �Q <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE fES 10 EFERRED TO SITE MITIGATION FOR EVALUATION YES 40 <br /> ATE REFERRED / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> :VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />