Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL nt L H DIVISION <br /> f. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY` WEEPS CODE <br /> DDRESS TANK ID # <br /> TANK SIZE I IFUEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> ** <br /> Is permit current? es o ermit # IFacility Status Code oc.Soil/GW Cont 1YesIo <br /> umber of Tanks at facility ge of Tanks(if available) --F;;;-of Tank teel Fbrgl ngl Dual <br /> III. TANK HISTORY <br /> as Tank tested7 es o ailed precision test ? es o If yes, give date(s) <br /> as a repair made to the tank system? Yes No 11f yes, what was repaired? <br /> ns repair done under inspection? es No ere soil samples analyzed? 1Yes I 10 TXE PH-G IT <br /> PH-D b/EDB <br /> IT ype of failure/discharge atastrophic long-term leakage verfill I Inknown ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es I IN01 epth to Ground Water q.S of/Year lv verage Annual Precipitation N= 4 10-25 <br /> Site Welt(s) es o umber & Type Irr om ub <br /> S Score S Score S Score <br /> istance to Wells) 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 condition R ondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) tl�_�r >100 1-100 S 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) '0 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 /> Df leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> inique site features: Recharge area, coarse soil, nearby wells. Q At least ore than <br /> xxxx None l one one <br /> COLUMN TOTALS—TOTAL POINTS ) D + oz ( + <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> B I T X E B T E <br /> X J MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 Ti. 1. NA\3 <br /> Sample Result: ASOLINE 1000 100 10 <br /> 3 11f� AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> _7 V TPH IESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the teaching 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 BTX&E 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 TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure 1Yes o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE CCMPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 I EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> .VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />