Laserfiche WebLink
SAN JOAQUIN COM7rY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL1(D[VISION <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> ATE / J� 7 <br /> AME OF FACILITY �/ % -"� <br /> DORES$ �•`%(j? <br /> r � <br /> ANK SIZE UEL TTPE <br /> II. GENERAL SITE HISTORY <br /> Is permit current7 as o armit k acili ty Status Code oc.Soil/Gu Cant es <br /> 0 <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tank teal Fbrgl ngl Dual <br /> III. TANK HISTORY <br /> @YPQof <br /> tested? as o ailed precision test ? es o If yes, give date(s) <br /> pair made to the tank system? as No f yes, what was ,repaired? <br /> ,Isir done under inspection? as 0 <br /> are <br /> soil samples analyzed? as to TXE PH•G PM-D b/EDD <br /> failure/discharge atastroph is long•;e rm leakage vert ill nknown cher: <br /> IV, REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> 5oi t Samples Received as o epth to Ground Water of/Year <¢,G verege Annual Precipitation = 4 10.25 <br /> -Si ce welt(s) <br /> as o umber & Type Irr om u, <br /> S core S core S core <br /> ;stance to Wel l(s) from Tank ft; ft; ft C 0 pts C pts C pts <br /> 0 f 0 £ 0 f <br /> R ondition R ordition R ondi tion <br /> Site Feature - Leeching Potential Analysis / is me[ E is met E s met <br /> ini mum Dap cn to groundwater from the Soil Sample (feet) / 7 >100 1.100 25-50\1 <br /> raE <br /> n subsurface (applies [o foothills or mountain areas) �� None Unknown resent <br /> veual Precipitation (inches) ! xxxxx <10 9 10.25 xxxxxx 26-40\2 <br /> on•MOOe conduits which increase vertical migration <br /> 1 leachate (i.e., septic systems, water wells, ponds) None Unknown 5/ resent <br /> )nique site features: Recharge area, coarse soil, nearby welts. At least are than <br /> xxxx None one (7� one <br /> COLUMN TOTALS»>TOTAL POINTS <br /> a-m-�ple Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or Less <br /> J/(// /V � S T X E a TX E <br /> MAXIMUM ALLOWABLE B•i•%-E LEVELS (PPM) 1 50 50 50 .3 J X 1. Na\3 <br /> ample Resul[: ASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPN LEVELS (PPM) <br /> TPN IESEL 10,000 1000 100 <br /> OOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete ;he Leaching 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 <25 ft., do not Use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTXBE are net applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are STX d E or TPN Concentrations > Allowable Levels Yes �Fo <br /> I2. Recommend Site Closure !Yes I No I I If Yes, Refer [o Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES O EFERRED TO SITE HITIOATION FOR EVALUATION ES !O <br /> ATE REFERRED / / AtE CLOSURE LETTER MAILED <br /> AME DF <br /> .'VALUATOR <br /> Em 23 80 (UGTWKSHT)\5/90 <br /> ;'h 29 30 <br />