Laserfiche WebLink
I SAN JOAQUIN TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE- DIVISION <br /> I• UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE C - -7 <br /> NAME Of FACILITY /�.�J r.. l ,�[, _� �� '';WEEPS COOED a 3 r 7 ; <br /> ADDRESS 1 4.��'� ��'L- f TANK IO # ! _� f <br /> TANK SIZE ! FUEL <br /> II. GENERAL SITE HISTORY <br /> *** <br /> is permit current? YesNo Permit # -(� (ate3j5 Facility Status Code Doc.SaiL/GW Cont Yes Nallc <br /> r` I <br /> Number of Tanks at facility Age of Tanks(if available) dGtc Type of Tank lSteel Fbrgl Sngl Dual <br /> III. TANK HISTORY {.ff <br /> Was Tank tested? Yes No Failed precision test ? Yes F7 No If yes, give date(s) <br /> I <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? I <br /> Was repair done under inspection? Yes No Were soil samples analyzed? Yes No BTXE TPH-G TPH-D Pb/EDS <br /> Type of failure/discharge catastrophic hang-term Leakage overfill unknown other- <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil _50Samples Received Yes No Depth to Ground Water �I Ref/Year I & Average Annual Precipitation A= 14 10-25 <br /> On-Site Wells) Yes No Number & Type Err Dan Pub i <br /> S Score S Score,;, S Score <br /> Distance to WeIL(s) from Tank ft; ft; ft C 10 pts C 4 pts. C 5 pts <br /> 0 if 0 if f: 1 0 if <br /> R condition R condition R condition i <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> Minimum Depth to groundwater from the Sail Sample (feet) I >100 I f51=100=. 15 1 <br /> 25-50\1 <br /> L 3 <br /> Fractures in subsurface (applies to foothills or mountain areas) ' None Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx X10 9 1 10-25xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration II <br /> of leachate (i.e., septic systems, water wells, ponds) None Unkno-in Present <br /> i <br /> Unique site features: Recharge area, coarse sail, nearby wells. At least More than i <br /> xxxxxx None one one <br /> S YVl'f B� COLUMN TOTALS»'TOTAL POINTS 1I D I', <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more �41 - 43 40 pts or Less <br /> p ,Co rw <br /> I <br /> N E 8� 3� V B T I X I E 9 JT X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 SO .3 .3 1. 1. NA\3 <br /> mpl Result I P� GASOLINE 1000 100 I 10 <br /> f{ �, aJ MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH DIESEL 10,000 1000 100 <br /> FOOTNOTES: ­if f 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 snit 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. I...ti': <br /> \3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or:100 ppm (diesel)- <br /> _ <br /> VT. STAFF RECOMMENDATION/tONCLUSION 1 7 g �L <br /> vels *Yes No <br /> II le Le <br /> 1. Are BTX & E or TPH Concentrations > <br /> ions Allowab <br /> 2. Recommend site Closure Yes No *If Yes, Refer to Site Mitigation for Evaluation I <br /> l <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 <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR I `' <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> t <br />