Laserfiche WebLink
SAN JOAQUIN COUNOUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTOISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY op <br /> SWEEPS CODE <br /> (ADDRESS O �n O TANK ID #1112q- <br /> TANK <br /> - <br /> TANK SIZE I�DD FUEL TYPE v� <br /> II. GENERAL SITE HISTORY <br /> •e* <br /> Is permit current? Yes No Permit # - Facility Status Code DOC.SOi L/GW Cont Yes No <br /> I Number of Tanks at facility Age of Tanks(if available) Type at Tank Steel Fbrgl'PC'SngL Dual <br /> 111. TANK HISTORY ` <br /> Was Tank tested? Yes No Failed precision test ? Yes Ro If yes, give dates) / /• / / <br /> !Was a repair made to the tank system? Yes No [f yes, what was repaired? <br /> Was repair done under inspection? Yes No Were soil samples analyzed? Yes INo BTXE TPH-G TPH-D Pb/EDB <br /> Type of failure/discharge catastrophic long-term Leakage overfill unknown other: (7 <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth co Ground Water Ref/Year Average Annual Precipitation A= 74 10-25 <br /> On-Site WeLL(S) Yes No Number & Type Irr Dam Pub <br /> B Score S Score �Sy Y, core <br /> Distance to Wel l(s) from Tank ft; ft; ft L ' 19 pts C 9 pts C S pts <br /> 0 if 0 if 0 if <br /> R condition R condition R condition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet) >100, jy 41400 ' 25-50\1 <br /> Fractures in subsurface (applies to foothills or'mountain areas) None Unknown Present <br /> 'Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> jof leachate (i.e., septic systems, water wells, ponds) None 01 Unknown Present <br /> ! <br /> (Unique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> xxxxxx None one one <br /> I Lf UMN 7QLS>»T L 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 /> r ' 8 T X E B T X E <br /> j N ,,J 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 /> MAXIMUM ALLOWABLE TPH LEVELS (PPM( <br /> _TPH DIESEL 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. 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 BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPN Concentrations > Allowable Levels *Yes No <br /> 2. Recommend Site Closure Yes No *If Yes, Refer to Site Mitigation for Evaluation) <br /> V11. REVIEW EVALUAT40N - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR 1ITH STAFF Red M' MiNDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES( NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />