Laserfiche WebLink
SAN AOAOUIW-64UNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL PN TH DIVISION <br /> I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE 5—16v <br /> !NAME OF FACILITY Y�� SWEEPS CODE <br /> �ADORESSTANK ID All IYu <br /> —0 Cl <br /> :511 D5 <br /> � <br /> TANK SIZE -1�00 FUEL TYPE '1(1/[{ 1 I ) (.� y17 V"F `D 1D $"{ b I <br /> Selit. GENERAL SITE HISTORY 5, D11306. p <br /> 4 <br /> ,Is permit current? Yes No )L Permit # - Facility Status Code DOC.SOLL/GW Cont Yes No <br /> INumber of Tanks at facility Age of Tanks(if available) Type of Tank Steel ;( Fbrgl Sngl Dual <br /> Ill. TANK HISTORY <br /> !Was Tank tested? Yes Na F.Red precision test ? Yes No If yes, give date(s) / <br /> :Was a repair made to the tank system? Yes No y If yes, what was repaired? <br /> was repair done under inspection? Yes No Were sail samples analyzed? Yes )CNo BTXE TPH-G TPH-D Pb/EDB <br /> ,Type of failure/discharge catastrophic long-term Leakage overfill X unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Sail Samples Received Yes X No Depth to Ground Waier `�� Ref/Year lAverage Annual Precipitation A= 14 10-25 <br /> i <br /> IOn-Site Welt(a) Yes No Number d Type Irr Dom Pub <br /> 5 ?Score S score 5 Score <br /> Distance to WeLL(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if O 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 51-100 25-50\1 <br /> !Fractures in subsurface (applies to foothills or mountain areas) NoneUnknown Present <br /> ',Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxnx 26-40\2 <br /> ,Man-Made conduits which increase vertical migration (,�' <br /> jof Leachate (i.e., septic systems, water wells, ponds) None 1 Unknown Present <br /> !Unique site features: Recharge area, coarse soiL, nearby wells. At )easel More than <br /> xxx <br /> xxxNone one one <br /> i <br /> COLUMN TOTALS>>>TOTAL POINTS " <br /> ;Sample Result: sSB T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or Less <br /> N�&66= o.Oleb <br /> X 0• <br /> Dog, �3( B T X E B T X E <br /> j MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> I <br /> iSampLe Result: GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> 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 soit or ground water.) <br /> \1 If depth is > 5 ft. and < 25 ft., scare 0 points. If depth <=5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levets for BTXBE 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) lr <br /> Va. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED DATE CLOSURE LETTER MAILED l/ / <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTYKSHT)\5/90 <br />