Laserfiche WebLink
SAN JQAOUIN COU:'- aUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALT!'-- `IISION <br /> I, I^ 40RKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY i /f?G �"l�t feSWEEPS CODE <br /> ADDRESS . 1�--rG� y� TANK ID 0 <br /> TANK SIZE FUEL TYPE a L y <br /> II. GENERAL SITE HISTORY i <br /> Is permit current? Yes No Permit x - Facility Status Code G Doc.So' /GW Cant Yes No <br /> Number of Tanks at facility ! Age of Tanks(if available) Z 12 Type of Tank Steel FbrgL SngE Dual <br /> III. TANK HISTORY <br /> was Tank test;;? Yes No Failed precision test 7 Yes Ho V If yes, give date(s) / <br /> Was a repair made to the tank system? Yes No VjIf yes, what was repaired? <br /> I <br /> Was repair done under inspection? Yes N4r were soil samples analyzed? Yes BTXE TPH-G TPH-0 Pb/EDB <br /> r <br /> Type of failure/discharge catastrophic long-term Leakage overfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH IN ECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR,LEACHING POTENTIAL ANALYSIS) <br /> SoiL Samples Received Yes IVVol I Depth to Ground water 4Ref/Year� ;8 Average Arcual Precipitation A= 14 10-25 <br /> On-Site weLl(s) Yes No Number b Type irr Dom Fub <br /> 5 Score S Score S Score <br /> Distance to well(s) from Tank N �–ft; ft; ft C 10 pts C 9 pts C 5 pts i <br /> 0 if 0 if 0 if <br /> R condition R condition R condition j <br /> V. Siva Feature - Leaching Potential Analysis E is met E is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet)L�p=�2 Z 8 >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None 9 Unknown Present <br /> i <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-Z5 xxxxxxx 26-40\2 <br /> i <br /> Man-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 soil, nearby weLLs. At least More than <br /> xxxxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or Less <br /> 8� �v D• E.2D 1a�ti - <br /> I <br /> = N• D• ,�,. B T X E B T X.LE2 ID M i MAXIMUM ALLOWABLE H-T-X-E LEVELS CPPM) 1 50 50 50 .3 .3 1. NA\3 <br /> Sample Result- m GASOLINE 1000 100 10 <br /> MAXIMUM ALLWABLE TPH LEVELS (PPH) <br /> LJ TPH DIESEL 10,000 1000 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 a 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 BTXBE are not applicable at a TAH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF.RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Al owabta 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 SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FORCLOSURETES ,V NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED (� / f \ +� DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />