Laserfiche WebLink
SAN JOAOUIIUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL 14TH DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE j_— �c - y3 <br /> AME OF FACILITY w7 '�e Favig)h1c,p COMA,/1 WEEPS CODE ( q n <br /> DRESS �L �,� �S d`h /v v/, ANK ID N <br /> TANK SIZE QJO I,,�_- UEL TYPE <br /> I1. GENERAL SITE HI STORY�GYid <br /> t� <br /> Is permit current? es o ermit 0 - acitity Status Code oc.Soil/GW ConC es o <br /> umber of Tanks at facility Be of Tanks(if available) ype of Tank tee( Fbrgl rgI Dual <br /> 111. TANK HISTORY <br /> Jas Tank tested? es o IF ailed precision test ? If <br /> es If es, give date(s) <br /> Jas a repair made to the tank system? es No f yes, who, was repaired? <br /> as repair done under inspection? es o ere soil samples analyzed? es o TXE I PH-L I PH-D I b/EDB <br /> Type of failure/discharge atas trophic long-term leakage verfill nknown ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Ifas !/ o epth to Ground Water SC of/Year I / ; EE verage Annual Precipitation = 4 11 <br /> 0-25 <br /> -Site Well(s) es o umber & Type Irr om ub <br /> S core S core 5 Score <br /> istance to Well(s) from Tank I ;.0 ft; ft; ft C 0. pts C pts C � pts <br /> 0 if 0 f 0 if <br /> R a0mition R ondition R ondition <br /> J. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> iniinm Depth to groundwater from the Soil Sample (feet) SCi _I1_33 >100 1-100 25-5011 <br /> Fractures in subsurface (applies to foothills or mountain areas) I (`) None Unknown resent <br /> verage Annual Precipitation (inches) xxxxxx <10 9 10-25 KXXXXXX 26-40 2 <br /> an-Made conduits which increase vertical migration <br /> t leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> pique site features: Recharge area, coarse soil, nearby wells. At least 4ore than <br /> xxxxx None _I one one <br /> COLUMN TOTALS»>TOTAL POINTS I c% t ' • I D 8 <br /> ample Result: III T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 411 pts 40 pts or less <br /> iv n 6t I +D,y}?�1h MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) Dt 50 50 50 .3 .3 1. 1. NAL <br /> ample Result: ND':.f(OGpi A /M/-F ASOLINE 1000 100 10 <br /> pp d ''// XINUM ALLOWABLE TPN LEVELS (PPM) <br /> Iv ( � ! ATPH--z- IESEL 10,000 1000 100 <br /> FOOTNOTES: ••-If documented soil and/or ground water contamination is present, do not cunplete the leaching potential <br /> analysis. (i.e., site is currently on UGT Contanina tion List for soil or ground water.) <br /> 11 If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> 12 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTX&E are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION Zy" <br /> 1. Are BTX & E or TPM Concentrations > Allowable Levels Yes o L/ I�,. � (ivp� �C d �Lr� <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation �Q (0CY.d✓1 &A <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR U �z � 1 <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES O <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF r // ( -1 <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />