Laserfiche WebLink
SAN JOAOUh- COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL"!dLTH DIVISION <br /> I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE _ <br /> i.VAME OF FACILITY l <br /> �l� e SWEEPS CODE a3 /D 8S <br /> !ADDRESS Is TANK ID #I G� _ / 71 O •f7 <br /> (TANK SIZE J!00o FUEL TYPE ✓ � ��� p_� V C <br /> (I. GENERAL SITE HISTORY /lf! <br /> Is permit current? Yes No Permit # <br /> ' Facility Status Code Doc.Sail/GWANK HISTORY Age of Tanks( <br /> Cant Yes No <br /> �NunTof Tanks at facility if available) 3$ Type of Tank Steel Fbrgl Sngl Dual <br /> ... <br /> TANK <br /> 'Jas Tank tested? Yes No Failed precision test 7 Yes xNo If yes, give dates) �r/ <br /> ;as a repair made to the tank system? Yes No If yes, what was repaired? <br /> Was repair done under inspection? Yes No"'Were soil samples analyzed? Yes INo BTXE TPH-G TPH-D Pb/EDB <br /> ;Type of failure/discharge catastrophic long-term leakage overfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Ground Water IRef/Yea r Average Annual Precipitation A= 14 10-25 <br /> iOn-Site Wett(s) Yes No Number 8 Type Irr Dom Pub <br /> 5 Score S Score S Score <br /> !Distance to Well(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 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) '/D- t (Q= >100 I I51-100 t 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) 'O None I Unknown I Present <br /> (Average Annual Precipitation (inches) Xxxxxx <10 9 1 10-25 xxxxxxx 26-40\2 <br /> -Man-Made conduits which increase vertical migration q <br /> of leachate (i.e., septic systems, water wells, ponds) None 1 Unknown Present <br /> Unicue site features: Recharge area, coarse soil, nearby wells. ^ At Least More than <br /> xxxxxx None Y one one <br /> COL TOTALS»>TOTAL POINTS /U . ,� 7 ( s 3? <br /> Samate Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pis or more 41 - 48 pts 40 <br /> K-3Al.yJT-d2yXZ71 <br /> s 3 E_ Iz}d ��/ B T X I E 8 T X E <br /> MAXIMUM ALLOWABLE 8-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. ypot�tia <br /> Sample Result: � GASOLINE 1000 100 PNG = 4 lowM4(MUM ALLOWABLE TPH LEVELS (PPM)TPH DIESEL 10,000 1000FOOTNOTES: ocunented soil and/or ground water contamination is present, do not complete the analysis. (i.e., site is currently an UGT Contamination List for soil or groun\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 8TX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 <br /> V1. .Ar RECOMMENDATION/CONCLUSION (�i4PZ �-CE> <br /> �1�<-lam <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels I'Yesl No 0„ <br /> 2. Recommend Site Closure Yes No Refer to Site Mitigation far Evaluation ^D �tl�-/�*- <br /> VIZ. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR lY F.Y//� ddd���JJJJJJ <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE IYES NOI (REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED( / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />