Laserfiche WebLink
SAN JOAQUINY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAO DIVISION — <br /> 1. GST WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY SWEEPS CODE <br /> ADDRESS TANK ID # <br /> TANK SIZE (. FUEL TYPE <br /> II. GENERAL SITE HISTORY ri.* <br /> Is permit current? Yes No =Permit - Facility Status Code Doc.SOiI/GW Cont Yes No <br /> Number of Tanks at facility ' Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test ? Yes No If yes, give date(s) <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? <br /> Was Erepairdone under inspection? Yes No Were soil samples analyzed? Yes No BTXE TPH-G TPN-D Pb/EDBTypelure/discharge catastrophic long-term leakage overfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPE TION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> jSoil Samples Received Yes No Depth to Ground Water Ref/Year Average Annual Precipitation A= 14 10-25 <br /> jOn-Site Well(s) Yes No Number & Type Irr Dom Pub S Score S Score S Score <br /> jDistance to Wells) frau Tank ft; ft; 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 met E is met <br /> (Minimum Depth to groundwater from the Soil Sample (feet) >100 q 51-100 125-50\1 <br /> jFractures in subsurface (applies to foothills or mountain areas) None Unknown Present <br /> jAverage Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx) 26-40\2 <br /> i <br /> jMan-Made conduits which increase vertical migration b None Unknown Present <br /> !of leachate (i.e., septic systems, water wells, ponds) <br /> jUnique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> xxxxxx None one one <br /> I <br /> t F <br /> COLUMN TOTALS>>>TOTAL POINTS Z + + <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> J11 T X E B�T_j X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 50 50 50 .3 1. 1. NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) 100 <br /> NJ TPH DIESEL 10,000 1000 <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 <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISO /SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / DATE CLOSI LETTER MAILED / / <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />