Laserfiche WebLink
SAN JOAOUtim tts..fY PUBLIC HEALTH SERVICES/ENVIRONMENTAL 11,AL✓DIVISION / <br /> 1, UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE G Q <br /> AME OF FACILITY /GleGorrl ` rVh �� WEEPS CODE <br /> DDRESS �/)'�� ��(,GJ ANK ID k <br /> TANK SIZE ,� UEL TYPE �� <br /> 11. GENERAL SITE HI 6RY <br /> Is permit current? es o ermit k acility Status Code I IDoc.Soil/GW Cont os o <br /> umber of Tanks at facility ge of Tanks(if available) e of Tank teel Fbrgl ngl Dual <br /> yp <br /> III. TANK HISTORY <br /> as Tank tested? as I IHOI ailed precision test ? es o If yes, give date(s) <br /> as a repair made to the tank system? as No f yes, what was repaired? <br /> ns repair done under Inspection? es No ere soil samples analyzed? es to T%E j PH-G PH-D b/ED0 <br /> type of failure/discharge atastrophic Iong-term leakage verfill nknown Cher: <br /> IV, REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR If LEAC ING POTENTIAL ANALYSIS) <br /> soil Samples Received es I INoepth toGround Wate f/Year verage Annual Precipitation = 4 10-25 <br /> )n-Site Wells) as o ilumber & Type Irr om I ub <br /> S Score S Score S Score <br /> Distance to Well(s) from Tank ft; ft; ft C 10 pts L 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R condition R condition R ondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1.100 �� 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) Q None Unknown resent <br /> verage Annual Precipitation (inches) KXXXAA <10 9 10-25 xxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration PZ <br /> RCT k� <br /> f leachate (i.e., septic systems, water wells, ponds) <br /> None Unknown resent <br /> Inique site features: Recharge area, coarse soil, nearby wells. At least ore than <br /> xxxxxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS '1 * * 93 <br /> ;ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or-less <br /> MAXIMUM ALLOWABLE D-T-X•E LEVELS (PPM) 1 50 50 50 .3 .3 1. NA\3 \1 <br /> -ample Result: ASOLINE 1000 100 10 <br /> �p 1� A%IMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPN — IESEL 1 10,000 1000 100 <br /> OOTNOTES: ***If documented soft and/or ground water contamination is present, do not complete the Leaching ential <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 /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTX&E are not applicable at a TPN concentration of 10 p (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1, Are BTX & E or TPH Concentrations > Alloua a Levels Yes o L <br /> 2. Recommend Site Closure es I I/ro If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> -ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 I 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 /> Ex 29 80 <br />