Laserfiche WebLink
SAN JOAOUITY PUBLIC HEALTH SERVICES/ENVIRONMENTAL DIVISION <br />I, UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE( <br />NAME OF FACILITY I S,®(SWEEPS CODE <br />ADDRESS TANK IQ * - /% <br />TANK SIZE FUEL TYPE <br />rT r.FUFQA1 SITE HISTORY <br />s permit current? Yes No Permit N - Facility Status Code Doc.SoiL/GW Cont Yes No <br />umber of Tanks at facility Age of Tanks(if available) Type of Tank ISteel Fbrgl Sngt Dual <br />III. TANK HISTORY <br />Was Tank tested? <br />Yes <br />YES NO <br />No <br />Depth to Ground Water <br />Failed precision test ? <br />Yes <br />1XI <br />No If yes, give date(.) <br />On -Site Wells) <br />Has a repair made to the tank system? Yes No <br />If yes, what was rewired? <br />Was repair done under inspection? Yes 7No Were soil samples analyzed? Yes No! <br />BTXE <br />Irr <br />TPH-G TPN -D Pb/EDB <br />Pub! <br />Type of failure/discharge <br />catastrophic 'long-term leakage <br />overfill unkno+mn <br />other: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING PUTENIIAL ANALTaiaO <br />Soil Samples Received <br />Yes <br />YES NO <br />No <br />Depth to Ground Water <br />Ref/Year <br />Average Annual Precipitation <br />A= 14 <br />10-25 <br />On -Site Wells) <br />Yes <br />No <br />Number & Type <br />Irr <br />Dom <br />Pub! <br />S <br />Score <br />10 pts <br />S <br />C <br />Score <br />9 pts <br />S <br />C <br />Score <br />5 pts <br />Distance to Wells) from Tank ft; ft; ft C <br />0 <br />if <br />condition <br />is met <br />0 <br />R <br />E <br />if <br />condition <br />is met <br />0 <br />R <br />E <br />if <br />condition <br />is met <br />R <br />V. Site Feature - Leaching Potential Analysis E <br />Minimum Depth to groundwater from the Soil Sample (feet) <br />I >100 I <br />151-100 <br />25-50\1 <br />Fractures in subsurface (applies to foothills or mountain areas) , <br />` None <br />Unknown <br />IPresent <br />Average Annual Precipitation (inches) xxxxxx <br /><10 <br />I 9 110-25 <br />Ixx:o = <br />26-40\2 <br />Man -Made conduits which increase vertical migration <br />of leachate (i.e., septic systems, water wells, ponds) <br />None <br />Unknown <br />Present <br />Unique site features: Recharge area, coarse soil, nearby wells. <br />( <br />At least <br />More than <br />xxxxxx <br />None <br />one <br />one <br />COLUMN TOTALS»>TOTAL POINTS I b <br />+ <br />M <br />. <br />= <br />Sample Result: (B T X OR E) <br />RANGE OF TOTAL POINTS 49 pts or more <br />41 - 4a pts <br />I 40 pts or less <br />6l <br />B <br />T XE <br />B <br />JT <br />X <br />E <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) 1 <br />50 50I 50 <br />I <br />I .3 <br />.3 <br />1. <br />1. <br />I NA\3 <br />Sample Result: <br />1000 <br />100 <br />I 10 <br />MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br />HGASOLINE <br />TPH <br />10,000 <br />1000 <br />I 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 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 No <br />2. Recommend Site Closure Yes No If Yes, Refer to Site Mitigation for Evaluation d <br />F a <br />VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR 4 <br />CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE <br />YESI INOI (REFERRED TO SITE MITIGATION FOR EVALUATION <br />YES NO <br />DATE REFERRED / / <br />DATE CLOSURE LETTER MAILED <br />NAME OF <br />EVALUATOR <br />EH 23 80 (UGTWKSHT)\5/90 <br />