Laserfiche WebLink
SAN JOACUIN CCUOPUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTF�ISION <br /> I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> nME OF FACILITY EEPS CODE,� �C.f�C�+-� <br /> ANK ID At Z, <br /> ,DOR'c 55j �� i�G-r77cl G� /� L�" <br /> LANK SIZE �Gi9OG� UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> Is permit current] es o ermit R - acStatus Code 3/ oc.Soil/GW Cont es o <br /> umber of Tanks at facility ,j Be of Tanks(if available) ✓A k YPe of Tank teal rgl ng( Dual <br /> III. TANK HISTORY <br /> Jas sank tested? es o ailed precision test 7 es o If yes, give date(s) <br /> as a repair made to the tank system? es No % f yes, what was repaired? <br /> as repair done under inspection? es o / ere soil samples analyzed? es o E PH-G PH-D b/EDB <br /> 1-1- <br /> type of failure/discharge atastrophic long-term leakage ver;ill nknowntey: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received as o epth to Ground Water "� of/Year L; verage Amual Precipitation = 4 0-25 <br /> )n-Site Wells) es 2 o umber 8 Type Irr an ub <br /> S 3core S Score S 3core <br /> istance to Wells) from Tank ft; ft; ft L 10 pts L Pts C 5 pts <br /> 0 if 0 if 0 if <br /> R ondition R cordition R condition <br /> J. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inim Depth to groundwater from the Soil Sample (feet) >100 1.100 CD 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None �' Unknown resent <br /> verage Annual Precipitation (inches) KXXxxX <10 9 10-25 xxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> pique site features: Recharge area, coarse soil, nearby wells. At least 4ore than <br /> xXXX None one one <br /> COLUMN TOTALS»>TOTAL POINTS * i (, <br /> Sample Result: (B T X OR E %h RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> .A /,Feed '� wDC2 <br /> B T % E B T X E <br /> Tyo boo X 60yOm o MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> ample Result: ASOLINE 1000 100 10 <br /> AXIMUH ALLOWABLE TPH LEVELS (PPM) <br /> '1Oc) TPH IESEL 10,000 1000 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 /> \1 If depth is > 5 ft. end < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. pP" p (dieset). <br /> \3 Levels for BTXBE are not applicable at a TPH concentration of 10 (gasoline) or 100 <br /> V1. STAFF RECOMHENDAT ION/CONCLUSION <br /> 1. Are BTX $ E or TPH Concentrations > Allowable levels Yes o X <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/SENIOR <br /> -ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES EFERRED TO SITE MITIGATION FOR EVALUATION ES <br /> )ATE REFERRED / 7 /'r� ATE CLOSURE LETTER MAILED <br /> JAME OF <br /> ;VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />