Laserfiche WebLink
I. <br />NAME OF FACILITY- <br />HE :SS] J T <br />TANK SIZE a JT <br />SAN JOAQUIN COM PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALViStON <br />LW SHEET FOR SITE CLOSURE EVALUATION DATE <br />t�l3r-.tL� <br />tre <br />Is permit current? Yesix No Permit S 3q Facility Status Code Doc.Soit/GW Ca"YesNo <br />Number of Tanks at facittty Age of TanksClf available) Type of tank Stent Fbrgl <br />lit. TANK HISTORY <br />was Tank test ed't <br />Yes <br />No <br />Fatted precision test Y <br />Yes <br />Ref/Year <br />No <br />Ef <br />yes, give dates) <br />14 <br />Was a repair mach to the tank system? Yes No <br />If yes, what was repaired? <br />Was repair dans under Inspection? <br />Yes No Were soil samples analyzed? <br />Yes <br />No <br />BTXE <br />TPN -G <br />Irr <br />TPH-D <br />Pb/EDT <br />Type of failure/discharge <br />Pub <br />catastrophic long -rata leakage <br />overfill <br />other: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />Soft Samples Received Yes <br />No <br />Depth to Ground Water <br />Ref/Year <br />Average Annual Precipitation <br />A� <br />14 <br />10-25 <br />On -Site WeltCs) <br />Yes <br />No <br />Number & Type <br />Irr <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 WeLLCs) from Tank <br />ft; ft® ft C <br />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 Soft Sample (feet) <br />>100 <br />51-100 <br />25-50\1 <br />Fractures in subsurface (applies to foothills or mountain areas) <br />Nave <br />Unknown <br />Present <br />Average Annual Precipitation (inches) xxxxxx <br /><10 <br />9 <br />10-25 <br />xxxxxxx <br />26-40\2 <br />Man -Made conduits which Increase vertical migration <br />of teachate (i.e., septic system, water wells, ) <br />None <br />Unknown <br />Present <br />Unique site features: Recharge area, coarse soft, nearby welts. <br />At Least <br />More than <br />xxxx= <br />Nont <br />one <br />one <br />COLUMN TOTALS),>aTOTAL POINTS ` • <br />_ <br />Sample Result: CB T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts <br />40 pts or Less <br />T T X E B TX E <br />MAXI ALL lE 3•T -X -E LEVELS CPPM) t 50 50 50 .3 .3 1. 1. <br />I I <br />NA\3 <br />Sample Result:INE 1000 100 <br />10 <br />MAXEMtAI ALLOWABLE TPN LEVELS CPPM) <br />TPN DIESEL 10,000 1000 <br />100 <br />FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not compteu the teaching potential <br />analysis. Cf.e., site is currently on UGT Contamination List for soft or grohrd 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 STX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br />Vt. STAFF RE NOATION/CONCLUSION <br />1. Are BTX t E or TPH Concentrations > Allowable Levels *Yes No <br />2. Raccemend Site Cloore Yes No If Yes, Refer to Site Mitigation for Evaluation <br />VII. REVIEW EVALUATION - TO BE COMINLETED BY A VISOR/SENICR <br />CONCUR WITH STAFF RECCMMEMDATIOM FOR CLOSURE YES NO IREFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br />DATE REFERRED / / DATE CLOSURE LETTER MAILED / <br />NAME IF <br />EVALUATORI <br />EH 23 d0 (UGTVKBHT)\5/90 <br />