Laserfiche WebLink
SAN JCAo"'4 COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENT. 'EALTH DIVISION <br /> I. UGST WORKSHEET FOR SITE CLOSURE EVALUAT,. DATE i <br /> NAME OF FACILITY SWEEPS CODE( 3 <br /> ADDRESSI ,313 1 D Gr-C ITANK iD 3I �.- <br /> TANK SIZE 10 OOC) IFUEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> Is permit current?IYes No IPermit A - IFacility Status Code Doc.Scil/GW Cant I Yes INo <br /> (Number of Tanks at facility Age of Tanks(if available) Type of Tank Steell Fbrgl ISngII Dual <br /> III. TANK HISTORY <br /> Was Tank tested?IYes I No Failed precision test ? Yes No If yes, give date(s)I <br /> was a repair made to the tank System? Yes No If yes, what was repaired? <br /> I <br /> Was repair done under inspection? Yes No Were soil samples ana lyzed7 Yes INoI BTXEI (TPH-GI ITPH-DI Pb/ED8 <br /> Type of failure/discharge Icatastrophic long-term leakage) overfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Sail Samples Received Yes No IDepth to Ground Water IRef/Year l Average Annual PrecipitatianlA= 14 10-25 <br /> On-Site 4ell(s)IYes No INumber & Type ITT IDom Pub <br /> S Score TcR) -,�f <br /> S Score <br /> (Distance to Wells) from Tank ft; ft; ft C 10 ptsC 5 is <br /> 0 if 0 ifpR condition R condition <br /> IV. site Feature - Leaching Potential Analysis E is metE is met <br /> Minimum Depth to groundwater from the SoiL Sample (feet) ��._ I >100 I51-100 I 125-50\1 <br /> IFraciures in subsurface (applies to foothills or mountain areas) J V I More I Unknown (Present <br /> Average Annual Precipitation (inches) xxx 1 00 9 110-25 �xxxxxxxl 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) I None Unknown I Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> xXnonxx None one one <br /> COLUMN 70TALS>>>TOTAL POINTS a <br /> SamuLe Result: (S T X OR E) RANGE OF TOTAL POINTS 49 pis or more I 41 - 48 pts I 40 pis or less <br /> SDc <br /> B r XE 8 T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50, 50 I .3 .3 11. 1. wA\3 <br /> Sample Result <br /> ( � y„ �GASOLINE 1000 100D L D i U - y� MAXIMUM aLLOWABI.E TPH LEVELS (PPM)'/ 1) .0ga— SEL 10,000 1000 I 100 <br /> FOOTNOTES: " If documented soil and/or ground water cantamination is present, do rot complete the Leaching potential <br /> analysis. (i.e., site is currently an UGr 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 TPH concentration of 10 ppm (gasolim) 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 Yesl No If Yes, Refer to Site Mitigatian for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SE.4IOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE I YESI NO (REFERRED TO SITE MITIGATION FOR EVALUATION I YES I INOI <br /> DATE REFERRED / / (DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />