Laserfiche WebLink
SAN JOAQU NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H DIVISION <br />I, UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br />AME OF FACILITYl?�` i`' ECOtD ID <br />ADDRESS TANK ID # - <br />TANK SIZE UEL TYPE ®` �` Is, C^ iU F Ac <br />II. GENERAL SITE HISTORY 9 <br />permit current? es o ermit lFacitity Status Code oc.Soil/GW Cont es I o <br />nber of Tanks at facility ge of Tank(if available) type of Tank tteet brgl ngl I Dual <br />Jas Tank tested? <br />es <br />I <br />o <br />lFailed <br />precision test ? <br />es <br />F <br />verage Annual Precipitationrmet <br />If yes, give date(s) <br />/ / / / <br />as a repair made to the tank system? Yes No <br />11f yes, what was repaired? <br />as repair done under inspection? <br />10 ere soil samples analyzed? es <br />ES <br />umber & Type <br />o <br />TXE <br />PH -G <br />I <br />PH -0 <br />b/EDB <br />ype of failure/discharge <br />core <br />0 pts <br />f <br />ondition <br />atastrophic tong -term leakage <br />core <br />pts <br />if <br />condition <br />verfill <br />istance to Wetl(s) from Tank <br />ft; ft; ft <br />ther: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />M <br />Soil Samples Received Ves <br />I <br />o <br />epth to Ground Water <br />of/Year <br />verage Annual Precipitationrmet <br />On-Si te Wells) <br />es <br />o <br />umber & Type <br />Irr <br />om <br />ub <br />S <br />core <br />0 pts <br />f <br />ondition <br />S <br />C <br />0 <br />R <br />core <br />pts <br />if <br />condition <br />S <br />C <br />0 <br />R <br />istance to Wetl(s) from Tank <br />ft; ft; ft <br />C <br />0 <br />R <br />V. Site Feature - Leaching Potential Analysis <br />E <br />is met <br />E <br />is met <br />E <br />inimum Depth to groundwater from the Soil Sample (feet) <br />>100 <br />1-100 <br />25-501 <br />Fractures in subsurface (applies to foothills or mountain areas) <br />None <br />Unknown <br />Exxxx <br />Present <br />Average Annual Precipitation (inches) xxxxxx <br /><10 <br />9 <br />10-25 <br />26-4052 <br />an -Made conduits which increase vertical migration <br />f leachate (i.e., septic systems, water wells, ponds) <br />None <br />Unknown <br />resent <br />pique site features: Recharge area, coarse soil, or wells. <br />(Muncipal=>2000 ft; domestic=>500 ft; irr/agricultural=present] Kxxxxx <br />None <br />At least <br />one <br />lore than <br />one <br />I pt ad 10'b COLUMN TOTALS>>>TOTAL POINTS <br />+ <br />+ <br />Sample Result: (B T X OR E) RANGE OF TOTAL POINTS E9 <br />0.®3D <br />f® �,16 `�(' ® <br />7T!�MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) <br />pts or more <br />B T X E <br />1 50 50 50 <br />41 - 48 pts <br />40 pts or less <br />B=1_ <br />.3. <br />NA53 <br />Sample Result: T SOLINE <br />1000 <br />100 <br />10 <br />g'0 IMUM ALLOWABLE TPH LEVELS (PPM) <br />TPH FESEL <br />10,000 <br />1000 <br />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 />51 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 />53 Levels for STX&E are not applicable at a TPN concentration <br />of 10 ppm (gasoline) or 100 ppm (diesel). <br />n <br />VI. STAFF RECOMMENDATION/CONCLUSION 6• S.;"T ® C11W, Imo- <br />1. Are BTX & E or TPH Concentrations > Allowable levels Yes o . ' ® 1 yo <br />, C a, <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 CLOSURE ES EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br />ATE REFERRED / / ATE CLOSURE LETTER MAILED <br />AME OF <br />EH 23 80 (UGTWKSHT)\5/94 <br />