Laserfiche WebLink
SAN JOAQU19--ANTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL OL.� H DIVISION <br /> I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE I i/ Z <br /> AME OF FACILITY Da�1d J� WEEPS CODE �Z <br /> ADDRESS 6�U 0 !� ANK ID # <br /> TANK SIZE UEL TYPE <br /> 11. GENERAL SITE HISTOQY / <br /> Is permit current7 eso ermit # acility Status Code oc.soil/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if availabte) ype of Tank ISteel Fbrgl I ISngL Duat <br /> III. TANK HISTORY <br /> as Tank tested? es o ailed precision test ? es o If yes, give dates) I[/ <br /> as a repair made to the tank system? es No I f yes, what was repaired? <br /> ns repair done under inspection? qo ere soil samples analyzed? 1Yes Jo TXE PH-G PH-D b/EDB <br /> ype of failure/discharge atastrophic Long-term leakage verfill nknown ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es I lNol epth to Ground Water of/Year lAverage Annual Precipitationrondition <br /> site Wells) es 0 umber & Type Irr om ub <br /> S core S core 5 <br /> istance to Welt(s) from Tank ft; ft, ft C 0 pts C pts C <br /> 0 if 0 if 0V. R ondition R ondition R <br /> Site Feature - leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Sail Sample (feet) >100 1-100 Q 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) p None Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 xxxxxxx 26-40\2 <br /> "nn-Made conduits which increase vertical migration <br /> Df leachate (i.e., septic systems, water welts, ponds) None Unknown resent <br /> Inique site features: Recharge area, coarse soil, nearby wells. At least lore than <br /> xxxxx None ` one one <br /> COLUMN TOTALS»>TOTAL POINTS + + <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS F9 pts or more 41 - 48 pts 40 pts or less <br /> B i X E B JT X E <br /> MAXIMUM ALLOWABLE R-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 i. 1. NA\3 <br /> Sample Result: ASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> FOOTNOTES: ***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 <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure 1Y <br /> es o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES JO <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> .VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> Ex 29 60 <br />