Laserfiche WebLink
SAN JOAQUI JNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL OH DIVISION <br /> I. <br /> UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY M, ECORD ID <br /> ADDRESS LANK ID # <br /> TANK SIZE / UEL TYPE QS�E pe <br /> II. GENERAL SITE HISTORY <br /> Is permit current? es o ermit # - acitity Status Code oc.Soil/GW Cont es o <br /> Number of Tanks at facility ge of Tank(if available) I LAOL type of Tank teel Llbrgt ngl I Dual, <br /> III. TANK HISTORY <br /> as Tank tested? es o ailed precision test ? es o If yes, give date(s) <br /> as a repair made to the tank system? es No 1 11f yes, what was repaired? <br /> as repair done under inspection? Les o ere soil samples analyzed?kes I o I TXE PH-G PH-D b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfitt nown I lother: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es o epth to Ground Water IS of/Year a&u IISS erage Annual Precipitation A= 4 0-25 <br /> On-Site Wells)Ts o umber & Type Irr am ub <br /> S core S Score S Le*�o <br /> istance to WeLL(s) from Tank ft; ft; ft C 0 pts C 9 pts C5 <br /> s L <br /> 0 f 0 if 0 'f 1 <br /> R ondition R condition R onditioq( <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 25-50L <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> Average Annual Precipitation (inches) KXXXXX <10 9 10-25 xxxxxxx 26-402 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown >resent <br /> pique site features: Recharge area, coarse soil, or wells. At Least 4ore than <br /> [Muncipal=>2000 ft; domestic=>500 ft; irr/agricultural=presentl Kxxxxx None one one <br /> COLUMN TOTALS>)TOTAL POINTS + + <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> CW in F4 <br /> ,��••® M ® B T X E B JT X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 150 .3 .3 1. 1. NA,L3 <br /> Sample Result: ASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH1p) IESEL 10,000 1 1000 100 <br /> FOOTNOTES: ***If 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 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 TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes I o <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSUREES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/94 <br />