Laserfiche WebLink
SAN JOAOUI. AUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL IN DIVISION �i <br /> I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION""� ATE I.(. _)41 <br /> AME OF FACILITY 1 t, k IdylI\1 c EEPS CODE �, �ZI <br /> D30-3N T� <br /> DDRESS I D3D . W L � U Vy ANK ID # <br /> TANK SIZE G' UEL TYPE <br /> I1. GENERAL SITE HISTORY <br /> Is permit current? es o ermit # acility Status Code 5� oc.Soi L/GW Cont es o <br /> umber of Tanks at facility I ge of Tanks(if available) Uyl� ype of Tank teel brgl ngI Dual <br /> 111. TANK HISTORY <br /> ms Tank tested? Ifes o ailed precision test ? es �ys, give date(s) <br /> as a repair made to the tank system? 1Yes No f yes, what was repaired? <br /> ns repair done wider inspeeticn7 es 40 ere soil samples analyzed?F <br /> as t:ja TXE I LVPH-G� PH-D I <br /> Type of failure/discharge atastrophic long-term leakage verfiLt nknown I la! <br /> cher: <br /> IV, REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samptes Received as P1 I <br /> epth to Ground Water of/Year verage Annual. Precipitation 4= 4 10-25 <br /> )n-Site Wells) as 1 11o f!r 8 Type Irr I om I ub <br /> S core 5 Score 5 core <br /> istance to Well(s) from Tank ft; ft; ft - C 10 pts C 9 pts C i pts <br /> 0 if 0 if 0 'f <br /> R oditi of R condition R onditi on <br /> Site Feature - Leaching Potential Analysis E is met E is met E s met <br /> iniax Depth to groundwater from the Soil Sample (feet) TJIOMV � >100 1-100 25-50\1 <br /> 45 <br /> ractures in subsurface (applies to foothills or mountain areas) 10 None Unknown resent <br /> verage AnnuaL Precipitation (inches) KXXXXX X10 9 10.25 xxxxxxx 26.40\2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown 5 resent <br /> Unique site features: Recharge area, coarse sail, nearby wells. At Least 4ore than <br /> %XXx None one One <br /> COLUMN TOTALS>>>TOTAL POINTS l(J + 1 (61 ID --;;13 <br /> ample Result: (B/T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or Less <br /> eT_ [ pL pf� B T X E <br /> MAXIMUM ALLOWABLE B•T-X•E LEVELS (PPM) 1 50 50 50 <br /> N .3 .3 1. 1. NA\3 <br /> amppiee Result: ^ ASOLINE 1000 100 10 <br /> W Nl� c2TPH en, AXIMUM ALLOWABLE TPH LEVELS (PPM) IESEL 1 10,000 1000 100 <br /> FOOTNOTES: --*If documented soil and/or ground water contamination is present, do not complete the Leaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> \1 If depth is > 5 ft. and x 25 ft., score 0 points. If depth x=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 (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION VrnC✓ VO6��OC ; a m TE-CTUMJ L/ l fk[TS <br /> 1. Are BTX 8 E or TPH Concentrations > AlLowabla�Levels Yes o cd1JJ GG�1 I QQ H G <br /> 2. Recommend Site Closure es o 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 EFERRED TO SITE MITIGATION FOR EVALUATION ES O <br /> ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> .VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />