Laserfiche WebLink
SAN JOAQUIWNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL 'H DIVISION <br />I UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br />NAME OF FACILITY Fipdlf. SWEEPS CODE l TSE <br />ADDRESS TANK ID # <br />c <br />TANK SIZE FUEL TYPE <br />TT_ GENERAL SITE HISTORY <br />permit current? Yes No 1XI <br />Permit # - Facility Status Code Doc.Soit/GW Cont Yes No <br />tuber of Tanks at facility Age of Tanks(if available) Type of Tank Steel INFbrgl Sngl Dual <br />III. TANK HISTORY <br />Was Tank tested? <br />No <br />No <br />Oe h to Ground Water <br />Failed precision test ? <br />Yes <br />Average Annuat Precipitation <br />Noy If yes, give ) <br />Was a repair made to the tank system? <br />Yes <br />No <br />If yes, what was repaired? <br />Was repair done under ins tion? <br />Yes <br />Err <br />Na <br />dere soil samples artalyz Yes No <br />BTXE' TPH-Gy <br />TPH-0 Pb/EDB <br />Type of failure/discharge <br />catastrophic <br />long-term leakage lz fill <br />unknown <br />other: <br />IV. REMOVAL HISTORY (ATTACH INSPECTIbR REPORT FOR SITE DETAILS/CECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />Soil Samples Received Yes <br />No <br />Oe h to Ground Water <br />Ref /Year <br />; <br />Average Annuat Precipitation <br />A= <br />14 <br />10-25 <br />On -Site Well(s) Yes <br />No <br />Number & T <br />Err <br />Dom <br />Pub <br />S <br />Score <br />10 pts <br />S <br />C <br />Score <br />9 pts <br />S <br />C <br />Score <br />5 pts <br />Distance to Wells) from Tank ft; ft C <br />177 0 <br />if <br />condition <br />is met <br />0 <br />R <br />E <br />if <br />condition <br />is met <br />0 <br />R <br />E <br />if <br />condition <br />is met <br />R <br />V. Site Feature - Leaching Potential Analysis E <br />Minimum Depth to groundwater from the Soil S le (feet) -� <br />>100 <br />( �51-100 <br />0 <br />"® <br />25-50\1 <br />Fractures in subsurface (applies to footfi' is or mountain areas ' <br />None <br />w*xxxmn <br />Present <br />Average Annual Precipitation (inches) xxxxxxy <br /><10 <br />9 <br />10-25 <br />lxxxxxxx) <br />26-40\2 <br />Man -Made conduits which increase ver cal migration <br />of leachate (i.e., septic systems, ter wells, ponds) <br />None <br />Unknown <br />Present <br />Unique site features: Recharge ea, coarse soil, nearby wells. <br />At least <br />Mare than <br />xxxxxx <br />None <br />aye <br />one <br />COLUMN T ALS»>TOTAL POINTS <br />+ <br />1 <br />+ <br />j <br />Sample Result: (B T X OR E) NGE OF TOTAL POINTS 49 pts or a <br />41 - 48 pts <br />40 pts or less <br />IV `z: 370 6—Z,A i MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) 1 50 50 50 <br />.3 <br />.3 <br />1. <br />1. <br />NA\3 <br />Sample Result: <br />GASOLINE 1000 <br />100 <br />10 <br />a <br />MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br />DIESEL 10,000 <br />1000 <br />100 <br />-a TPH <br />FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not late the leachi entiat <br />analysis. (i.e., site is currently on UGT Contamination List for s it or ground water.) <br />\1 I depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do no use table. <br />\2 f precipitation is > 40 inches, score 0 points. <br />\3 bevels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasol ne) or 100 ppm (dieset). <br />VI. STAFF RECOMMENDATSVON/CONCLUSION <br />1. Are BTX & E or TPH.Cdncentrations > Allowable Levels -Yes No F <br />15< ® 6;7e2. Recommend Site Closure Yes No *If Yes, Refer to Site Mitigation for Evaluation e <br />`� <br />VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br />CONCUR WITH STAFF RECOMMENDATION FOR CLOSUREIYES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br />DATE REFERRED / I DATE CLOSURE LETTER MAILED <br />NAME OF <br />EVALUATOR <br />EH 23 80 (UGTWKSHT)\5/90 T / - <br />6c " , 7 <br />