Laserfiche WebLink
SAN JOAQUIN t Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE' DIVISION <br /> j• -OGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> DaTE <br /> NAME OF FACILITY <br /> I SWEEPS COOE I a <br /> 1-7 <br /> 1ADORESS E. R I TANK ID d <br /> TANK SIZE FUEL TYPE vv <br /> I �jI. GENERAL SITE HISTORY <br /> Is permit current? Yes No Permit - Facility Status Code DOC.Soil/GW Cant Yes No <br /> Number of Tanks at facility Age of Tanks(if available) a Type of Tankisteel Fbrgl Sngl Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes Na failed precision test ? Yes Na IIf yes, give date(s) 51 /a© <br /> Was a repair made to the tank system? Yes Na If yes, what was repaired? <br /> Was repair done under inspection? Yesl Nol Were soil samples analyzed? Yes INoI BTXE TPH-G TPH-p Pb/EDB <br /> Type of failure/discharge catastrophic hang-tern leakage overfill Iunknowni other: <br /> IV. ,REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS)3�r. .-- <br /> Soil Samples Received Yes Nol Depth to Ground Water301 Ref/Year g'6 Average Arcual Precipitation A=I14 10-25 <br /> On-Site Wells) Yes No Number it Type Irr Dam Publ <br /> S Score S Score S Score <br /> Distance to Well(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> O if 0 if 0 if <br /> R condition R condition R condition <br /> V. Site Feature - Leaching Potential AnalysisE is met E is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet) I >100 I 51-100 I40 1 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None I Unknown I Present <br /> Average Annual Precipitation (inches) xxxxxx# <10 I 9 110-25 Ix.x=x 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) ` None I Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> }+ xxxxxx None onel one <br /> ! ,A 4,COLUMN TOTALS»-TOTAL POINTS � O + I l F + I O = m <br /> Sample Result:-(B T4 OR E) RANGE OF TOTAL POINTS 49 pts or more I 41 - 4a pts 1 ;;1 or les <br /> !jd 1` t X-A IMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50I 50 I .3 �.3 1., 1 3 <br /> Sample Resu�• `"� GASOLINE 1000 100 0p1 VV &! Z/ �c,5 MAXIMUM ALLOWABLE TPH LEVELS (PPM)TPH0IE5E1 10,000 1000 0 <br /> FOOTNOTES: **'*If documented soil and/or ground water contamination is present, do not complete the aching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground wa <br /> \1 if depth is > 5 ft_ and < 25 ft., scare 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 0 i ,$+ a 0'a of D <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels -Yes No ��ye� N <br /> Dls, <br /> 2. Recommend Site Closure Yes No If Yes, Refer to Site Mitigation for Evaluation 3 17— 7 <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YESI NO REFERRED TO SITE MITIGATION FOR EVALUATION YES MCI I <br /> DATE RE FEARED I DATE CLOSURE LETTER MAILED / / <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />