Laserfiche WebLink
SAN JOAQUIN CO-UBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL. ISION GATE <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> k SWEEPS CODE <br /> NAME OF FACILITY W Y�o <br /> TANK ID # - <br /> ADDRESS 7 <br /> FUEL TYPE <br /> TANK SIZE I 7� f/�O`i <br /> -0 2- K 17 I tsb6� <br /> I. GENERAL SITE HISTORY <br /> Facility Status Code <br /> is permit current? Yes No Permit # <br /> Oec.Soil/GG Cont Yes No <br /> Number of Tanks at facility Age of� Tanks(iType of <br /> f available) lank Steel Fbrgl Sngl Dual <br /> :il. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision ,test ? Yes No If yes, g1 <br /> ve date(s) <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? <br />` Was repair dare under inspection? Yes No Were soil samples analyzed? Yes No BTXE TPH-G TPH-D Pb/EDS <br /> Type of failure/discharge catastrophic long-term leakage overfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Average Annual Precipitation A= 14 <br /> Soil Samples Received Yes No Depth to Ground Water '],�i Ref/Year� � <br /> 10 25 <br /> On-site WeLI(s) Yes No Number & Type Irr Dom Pub S Score S Score s Score <br /> Distance to Wells) from lank 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 /> Leaching Potential Analysis ; E is met E is met E is met <br /> V. <br /> Site Feature - Leat g <br /> >100 51-100 25- 1 <br /> Minimum Depth to groundwater from the Soil Sample (feet) <br /> Fractures in subsurface (applies to foothills or mountain areas) <br /> None Unknown resent <br /> Average Annual Precipitation (inches) <br /> xxxxxx <10 <br /> 9 10-25 x xxx 26-40\2 <br /> rticaL mi ration t <br /> conduits which increase vert 9 own Present <br /> Man-Made None <br /> of leachate (i.e., septic systems, water wells,' ponds) <br /> At lea y More than <br /> Unique site features: Recharge area, coarse soil, nearby wells. xxxxxx) None one one <br /> N e x-t -r'o Dell t4 <br /> COLUMN TOTALS>>>TOTAL POINTS <br /> Sample Result: (B T X OR E) <br /> { RANGE OF TOTAL POINTS 49 p or more 41 48 pts 40 pts or <br /> x=t0.`W, <br /> S T X E � T X E <br /> MAXIMUM ALLOWABLE B=T-X-E LEVELS (PPM) 1 5O 50 50 .3 .3 1. 1. NA\3 <br /> r GASOLINE 1000 100 1 <br /> Sample Result: ' <br /> pry,-N-C., MAXIMUM ALLOWABLE TPNH LEVELS (PPM) 100 <br /> ��s+ DIESEL 10,000 1000 <br /> I3�•►tp.s g•L TPH_ C <br />� :** and/or round water <br /> contamination is present, do not complete the. chi <br /> FOOTNOTES: if documented soil / S for Soil or ground water.) <br /> analysis. (i.e., <br /> site isocurrently on UG7 Contamination List <br /> \1 If depth is > 5 ft. and < 25 ft-, score 0 paints: 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 /> L l <br /> 1. Are BTX & E or TPH Concentration^, > Allowable Levels. *Yes No 77,b <br /> 2. Recommend Site Closure Yes ND *If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISO SENIOR C/ <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES INOi REFERRED TO SITE MITIGAT]ON FOR EVALUATION YESNO <br /> f II <br /> DATE REFERRED DATELCLOSURE LETTER MAILED <br /> NAME OF Ort �1 <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />