Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> I• UC =SHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY SW.—..; CODE <br /> ADDRESS TANK ID X <br /> TANK SIZE FUEL TYPE <br /> II. GENERAL SITE HISTORY <br /> •ems <br /> Is permit current7 Yes No Permit it Facility Status Code Doc.SoiL/GW Cont Yes No <br /> Nuiber of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual <br /> 111. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test 7 Yes No If yes, give date(s) <br /> Was a repair made to the tank system] Yes No If yes, what was repaired? <br /> Was repair done under inspection? Yes No Were soil samples analyzed? Yes No BTXE TPH•G TPH•D Pb/EDB <br /> Type of failure/discharge catastrophic long-term leakage overfill unkn wn other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil SaapLes Received Yes No Depth to Ground Water Ref/Year Average Amual Precipitation A> 14 10-25 <br /> On-Site Wells) Yes No Nunber L Type Irr Dom Pub <br /> S Score S Score S Scare <br /> Distance to WeLL(s) frac Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R condition R condition R condition <br /> V. Site Feature . Leaching Potential Ara lysis E is met E is met E is met <br /> Minim Depth to groundwater from the Soil Sanple (feet) 35' >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown Present <br /> Average Annual Precipitation (inches) xxxzzx <10 9 10-25 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) None Unknaat Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> xxxxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS + <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> B T % E B T X E <br /> Y ' ' MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> 1 '\ MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPN - DIESEL 10,000 1000 100 <br /> FOOTNOTES: fe'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 grovel water.) <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth o5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> 111. STAFF RECCMME4DATION/CONCLUSION G eA/) J/Illl'i <br /> 1. Are 3TX 3 E or TPN Concentrations > Allowable Lavels I'Yas No <br /> 2. Recommend Site Closure Yes No •If Yes, Refer to Site Mitigation for Evaluation) <br /> '11I. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONGR WITH STAFF RECCSMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUAT'ON YESI NO <br /> OATS REFERREDI / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALJATOR <br /> EH 23 30 (UGTWKSHT)\5/90 <br /> -,r �vLJJ ta✓1 S rJT rV <br />