Laserfiche WebLink
SAN 1OAo"*4 COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENT➢' "EALTH DIVISION <br /> ), UGST WORKSHEET FOR SITE CLOSURE EVALUAT'.� DATE 7—/3_ <br /> NAME OF FACILITY ` ...r SWE-EPS CODE <br /> ADDRESS G V TANK LO $I -5 09 <br /> TANK SIZE( FUEL TYPE SHLvD i-, Ta.,i� <br /> 11. GENERAL SITE HISTORY <br /> is permit current?IYes INo (Permit 91_1 <br /> - (Facility Status Code) (Doc-Soi L/GW Cant Yes INo <br /> Number of Tanks at facility Age of Tanks(if available) (Type of Tank St leen Fbrgt ISngl Dual <br /> III. TANK HISTORY <br /> Was Tank tested?IYes No N <br /> Failed precision test ? Yes No If yes, give dare(s)I <br /> Was a repair made to the tank system? yesl No If yes, what was repaired? <br /> i <br /> Was repair done under inspection? Yes INo Were soil samples ana Lyzed? Tesl INo( BTXEI (TPH-GI (TPN-0 Pb/EDB <br /> Type of failure/dischargel catastrophic long-term Leakage) overfill unknown other- <br /> EV. <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received YesNa Depth to Ground Wateri/l Ref/Yearl Y& ; (Average ArvsaL Precipitation A= 14 110-25 <br /> On-Site Well(s)IYes MM.1 Number & Typel Irr I0omI Pub <br /> 5 Score S Scare S Score <br /> Distance to Wells) from Tank U ft; �0ft; ft C 10 pts C 9 pts C 5 pis <br /> O if 0 if 0 if <br /> R condition R condition R condition <br /> V. Site Feature - Leaching Potential Analysis E is me[ E is net E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet) I >100 151-100 I O 25-50\1 <br /> (Fractures in subsurface (applies to foothills or mountain areas) I None I I Unknown (Present <br /> Average Annual Precipitation (inches) z:vaxzl <10 1 9 1 10-25 Ixzazxxx1 26-40\2 <br /> Nan-Made conduits which increase vertical migration <br /> lof leachate (i.e., septic systems, water wells, ponds) I None I Unknown Present <br /> Unique site features: Recharge ares, coarse soil, nearby wells. I At Least More than <br /> zz:aax None one one <br /> COLUMN TOTALS>»TOTAL POINTS I a I a I = <br /> Sample Result: IS T X OR E) RANGE OF TOTAL POINTS 49 pis or more I 41 4a ptsI 40 pts or less <br /> s;ArLd l! T=AItpr-4., <br /> BT E 8 T X c <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1I 501 50 50 I 3 3 1 1. NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> 5� MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH w DIESEL 10,000 I 1000 I 100 <br /> FOOTNOTES: " If documented soil ardor ground water contamination is present, do not cmplere the Leaching potential <br /> analysis. (i-e., site is currently on UGT Contamination List for soil or graced water.) <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth <--5 ft., do nos 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 <br /> ppm (diesel). <br /> VI. STAFF RECCIMMENOATION/CONCLUSION D X <br /> V. Z <br /> 1. Are 8TH & E or TPH Concentratims > Allowable Levels "es) No �T-fN � CM �'FTJ <br /> Tl3�) D r �e1 �.TB�, <br /> 2- Recommend Site Closure Yes) Na If Yes, Refer to Site Mitigation for Evaluation Id Me t h <br /> 1— <br /> it <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIGR l AJ _ , DO o <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES INOI (REFERRED TO SITE MITIGATION FOR EVALUATIONIYESI NOI <br /> DATE REFERRED / / (DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> E4 23 80 (UGTWKSHT)\5/90 <br />