Laserfiche WebLink
SAN x4Q(IT� 'W7. PO -'ELIC HEALTH SERVICES/ENVIRONMEVj- a DIVISION <br />t• GS-. 'WORKSHEET FOR SITE CLOSURE EVAL! � � DATE _ <br />NAME OF FACILITY I� SWEEPS CODE O 3 <br />ADDRESS( ��U� S u "�vV1 TANK Io $ <br />TANK SIZE 5w IFUEL TYPE &,pJT C>0_ <br />11. GENERAL SITE HISTORY (� <br />------------------ <br />Is permit current) Yes No N Permit sI - Facility Status Code Doc.Soil/G1 Contly"I INoI <br />`Number of Tanks at facility) IAie of Tanks(If available)( Type of Yank) Steell IFbrgl ISngl Dual <br />III. TANK HISTORY <br />Was Tank tested? <br />Yes <br />(Depth S-eund Watery <br />No <br />Ref/year / ! <br />Failed precision test T <br />Yes <br />No If Yes, Hive date(s) <br />Was s repair made to the tank system? <br />Yes sol <br />IIf yes, w at.vas repaired? <br />Was repair done under inspecti onT <br />Yes <br />INo) <br />Were Boit samples ammiyZedT Yesl <br />- No <br />BTXEI, I\1 TPH-G <br />' TPH-DI IPh/EDBI <br />I <br />Type of failure/discharge) <br />Distance to WelUs) from Tank)tt; ft; ft <br />atastrophicI <br />Ilong-term Leakage <br />Minim, Depth to groundwater from the SoiL Samste (feet) <br />ovarfitl uah/zwf <br />l >ioa l <br />other: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FCR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />Q <br />Soil Samples Received Yes <br />No <br />(Depth S-eund Watery <br />a <br />Ref/year / ! <br />Average Aarval Precipitation) <br />Av 14 10-25 <br />On -Site WeII(s)IYes <br />No <br />(Number L Typal <br />Irrl <br />Dom <br />Pub <br />S <br />C <br />0 <br />R <br />'c <br />Score <br />10 pts <br />if <br />is mat <br />S <br />C <br />0 <br />; <br />-� <br />Score <br />9 pts <br />If <br />condition <br />lis met <br />S <br />C <br />0 <br />R <br />E <br />Sere <br />5 pcs <br />if , <br />S�ition <br />is met <br />Distance to WelUs) from Tank)tt; ft; ft <br />V. Site Feature - Leaching Potential Analysis <br />Minim, Depth to groundwater from the SoiL Samste (feet) <br />l >ioa l <br />51-100 <br />25-50\1 <br />Fractures in Subsurface (applies to foothills or mountain areas) <br />I None <br />Urhknoun <br />Present <br />Average Annual Precipitation (inches) <br />=r= <br /><10 <br />9 <br />c10d5 _ <br />lxsdm=l <br />Z5-40\2 <br />Man -Made conduits Which increase vertiaL migration <br />of Leachate (i.e., septic syste, ter nails, ponds) <br />msvo <br />Mone <br />Present <br />Unique site features: Recharge area, coarse soil, neanty vet Is. <br />)DOC= <br />N <br />At lent <br />arta <br />//, <br />I(L <br />More than <br />one <br />COLLIMM TOTALS»>TOTAL POINTS <br />• <br />. <br />I: <br />Sample Result- IS T X OR E) <br />� <br />2 ,2 (J RANGE OF TOTAL POINTS <br />49 pts or more <br />41 - 48 pts <br />40 -pts or less <br />MAXIMNI ALLZMLE B -T -X -E LEVELS (PPM) <br />B T I XI E <br />1 50 So 50 <br />8 T X E <br />.S .3 1. t. <br />NAV <br />Sample.Result: <br />TPN --G <br />MAXIMDR ALLOWA -7 '.PH LEVELS (PPM) <br />GASOLINE <br />t00o <br />l 100 <br />DIESEL <br />10,000 <br />l 1000 <br />100 <br />FOOTNOTES: —If doctmehted soil wil(or ground eater contamination is present, do not complete the Leaching potential <br />analysis. (i.e.. site is currently on UGT Contamination List for soil or ground voter.) <br />%1 if depth is > 5 ft. art < 25 ft., scare 0 points. If depth a5 ft., do not use table. <br />\2 If precipitation is > 40 inches, score 0 points. <br />\3 Levels for BTXLE are not applicable at a TPN concentration of la ppm (gasoline) or 100 ppm (diesel). <br />VI. STAFF RECOOHEENDATION/CONCLUSION <br />1. Are BTX b E or TPH Concentrations > Allocable Levets I'Yes INC <br />2. .Recommend Site CLosurelYes No 1�7>if Yes, Refer to Site Mitigation for Evaluation <br />VII. REVIEW EVALUATION - TO BE COMPLETED RT A IlpERVISCR/SENIOR / <br />CONCUR WITH STAFF RECOMMENDATION FOR CLOSJ7iI YES( <br />NOI (REFERRED TO SITE MITIGATION FOR EVALUATION <br />I YES MOI I <br />DATE REFERRED( <br />/ / b / ! DATE-ZLQSURE LETTER MAILEDI / / <br />NAME OF <br />EVALUATORI _ <br />EH 23 30 (UGTWKSHT)\5/90 <br />