Laserfiche WebLink
SAN JOAQUJ&INTY PUBLIC HEALTH SERVICES/ENVIRONMENTALH DIVISION <br /> I, UST WORKSHEET FOR SITE CLOSURE EVALUATION NO ATE 1 7�� y <br /> AME OF FACILITY l ECORD ID j J a67 <br /> ESS S ' - ANK ID # 3 <br /> FUEL TYPE r j <br /> 11. GENERAL SI E HISTORY J✓ <br /> ** <br /> Is permit current? es ocT7 aci11ty Status Code oc.Soil/GW Cont es o <br /> umber of Tanks at facility ge of Tank(if available) '�v ype of Tank teal Fbrgl rgl Dual <br /> 111. TANK HISTORY <br /> as Tank tested? es o ailed precision test ? es o 1f yes, give date(s) <br /> as a repair made to the tank system? es No 11f yes, what was repaired7 <br /> as repair done under inspection? es 40 ere soil samples analyzed? es o TXE PH-G PH-D b/EDB <br /> Type of failure/discharge atastrophic long-term leakage verfitL nknown ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oiL Samples Received es o epth to Ground Water of/Year verage Annual Precipitation = 4 0-25 <br /> )n-Site Well(s) IYes o umber & Type Irr I om ub <br /> S Score S Score S 3core <br /> istance to Well(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R ondition R conditi on R ondition <br /> Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 © 25-SOL <br /> Fractures in subsurface (applies to foothills or mountain areas) L) None Unknown resent <br /> verage Annual Precipitation (inches) xxxx <10 9 10-25 xxxxxx 26-40L <br /> an-Made conduits which increase vertical migration <br /> Df leachate (i.e., septic systems, water wells, ponds) lb None Unknown resent <br /> pique site features: Recharge area, coarse soil, or wells. At least ore than <br /> [Muncipa L=>2000 ft; domestic=>500 ft; irr/agricultural=present] "^lxxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS A O * * D <br /> ample Result: (B T X OR E) tMAtXIMUM <br /> RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or Less <br /> S W f3 Y40Pp0L. x-7 <br /> r 3(oOP B T X E 8 T X E <br /> rK, OWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. i 1 NA_\3 <br /> Sample Result: ASOLINE 1000 100 10 <br /> 7�.QQPp YM1' TP1f� AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH Q fESEL 10,000 1000 100 <br /> ---------- <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the leachi ial <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 191'S'a a'01' l gPiem "'a-<fpm. <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes o �0-a Cj/}yN.p ( Ea sf' X :r&9 0P.�rU1144 <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation LJ j /�pY/V 8' �J 1r� <br /> �pnL. 0 <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LE SENIOR f:8 s S d U Al 40 <br /> ONCUR WITH STAFF RECOMMENDATION=ESORRED TO SITE MITIGATION FOR EVALUATION ES 0ATE REFERRED / / MAILED <br /> AME OF <br /> VALUATOR c , y <br /> EH 23 80 (UGTWKSHT)\5/94 FYI 1f, �` <br />