Laserfiche WebLink
SAN JOAN. N COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAT'HEALTH DIVISION <br /> 1• UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE O p <br /> he LTD <br /> AME OF FACILITY �L �-� (' n 77 UE EPS CODE <br /> DRESS e�Lz ANK ID # <br /> ANK S12E �\��� UEL TYPE 2'C'LPc3r� <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? es o atonic # - acility Status Code 'f .� ' oc.Soi l/GW Cont es o <br /> umber of Tanks at facility f Tank teel Fbrgl ngl Dual <br /> 111. TANK HISTORY <br /> as Tank tested? es o ailed precision test ?4 es o If yes, give date(s) <br /> as a repair made to the tank system? es No ij f yes, what was repaired? i <br /> as repair done under inspection? es o ere soil samples analyzed? es o ,. T%E PH-G PH-D b/EDB <br /> Type of failure/discharge atestrophic 1, long-term leakage I verf111 nknown I lother: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es o epth to Ground Water of/Year verage Annual Precipitation = 4 0-25 <br /> -Site Wells) es o umber 8 TypFT <br /> rr <br /> e an .1bS core S core S core <br /> istance to Wellan <br /> s) from Tk ft; fq _ ft C 0 pts C pts C pts <br /> 0 if 0 if 0 f <br /> R ondltion p condition R oldition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sanple (feet) >101)>100 1-100 25-501 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> Average Annuat Precipitation (inches) xxxxxx <10 9 10-25 xxxxxx 26-40L <br /> an-Made conduits which increase vertical migration <br /> t leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> pique site features: Recharge area, coarse soil, nearby wells. /T At least ore than <br /> xzxxx None �fl one one <br /> i <br /> COLUMN TOTALS»>TOTAL POINTS t _ t �[ <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 40 pts 40 pts or less <br /> Tal * Cd B T X E H T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NAJ3 <br /> ample Result: ASOLINE 1000 100 10 <br /> _ AXIMUM ALLOWABLE TPN LEVELS (PPM) <br /> `fid L, TPH IESEL 10,000 ` 1000 100 <br /> OOTNOTES: ***If documented soil and/or ground water contanination is present, do not cpnplete 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 /> L If precipitation is > 40 inches, score 0 points. <br /> ,3 Levels for BTXBE are not applicable at a TPH concentration of 10 pp, (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes , . o <br /> I � <br /> 12. Recommend Site Closure res I NO I plf Yes, Refer to Site Mitigation for Evaluation <br /> VIII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> :VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />