Laserfiche WebLink
4 SAN 3OACUIN COW�i l LIC HEALTH SERVICES/ENVIRONMENTAL HEAL IVISLON <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE — <br /> NAME Of FACILITY /11G ISLEEPS CODE VF^� <br /> !ADDRESS �C•, - - TANK I6 413 <br /> :TANK SIZE1, FUEL TYPE <br /> i(. GENERAL Si E HISTORY <br /> ate* <br /> Is permit current? Yes No ' Permit x - Facility Status Code Oae.Soi,/GL Cont Yes No <br /> Number of Tanks at facility Age of Tanks(if available) ` Type of Tank Steel FbrgL SngL Dual <br />'II. TANK HISTORY <br /> I <br /> aas Tank tested? Yes filo Failed precision test T Yes No If yes, give dates) <br /> i <br /> vas a repair made to the tank system? YesNo If yes. what was repaired? � <br /> 'Jas repair done under inspection?pettian? Yes Na Were soil samples analyzed? Yes He BTXE TPH-G TPN-D Ph/EDB <br /> Tyre of failure/discharge catastrophic Long-term leakage overfill unknown other: <br />"I. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> it Samples Received Yes Na Depth to Ground Water Ref/Year Average Annual Precipitation A- 14 10-25 <br /> ..I-Site Wett(s) Yes No Number & Type Ire Dam Aub I <br /> S Score S Score S Score <br /> :Distance to Welt(s) from Tank ft, _f t; ft C 10 pts C 9 pts C 5 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 net E is met <br /> }Minimum Oepth to groundwater from the Soil Sample (feet �)lfel y100 I51-100 25-50\1 i <br /> Fractures in subsurface (applies to foothiLts or mountain areas) None j Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx� 26-40\2 <br /> Han-Made conduits which increase vertical migration <br /> ;of Leachate (i.e., septic systems, water wells, ponds) None Unknown Present <br /> Unique site features: Recharge area, coarse snit, nearby wells. At least More than <br /> xxxxxx Norse one ono <br /> I � <br /> COLUMN TOTALS»>TOTAL POINTS 0 + 1 91 + <br /> (Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or mare I 41 - 48 pts I 40 pts or Less <br /> 31 <br /> TTK(JK 5 '� n' i1�{�7 X MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50� 50� 50 ..3 I <br /> .3 I <br /> 1. 1.,� NA\3 <br /> s !v 3J <br /> SamplesulL- GASOLINE 1000 100 10 i <br /> �?' •a = 1 os Kul" ALLOWABLE TPN LEVELS (PPM) <br /> A Y TPH D DIESEL 10,000 1000 100 <br /> FOOTNOTES: '**if documented soil and/or ground rater contamination is present, do not camplato the Leaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> \1 If depth is y 5 ft. and < 25 ft., scare 0 points. If depth —5 ft., do not use table. <br /> \2 If precipitation is r 40 inches, scare 0 points. <br /> \3 Levels for STX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAF- -2ECCMMENDATlQN/C0NCLUSION <br /> 1. Are STX 3 E or TPH Concentrations > AlLowabte Levels 'Yes No <br /> 2. Recommend Site Closure Yes No If Yes, Refer to Site Mitigation for Evaluation L r8 - <br /> i Ill. REVIEW 'EVALUATION - TO 3E COMPLETED 3T A SUPERVISOR/SENIOR - <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES N0 REFERRED TO SITE MITIGATION FOR °VALUATION YES NO <br /> DATE REFERRED / 1 / DATE CLOMM LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 a0 (UGTWKS8T)\5/90 <br />