Laserfiche WebLink
SAN JOAW]t;,9TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL N��t, 1 DIVISION p <br /> I. 4 UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE LZ•3 6 <br /> AME OF FACILITY 1 RS &ct- Lc" W OV-K S SWEEPS CODE I 2 <br /> AORESS 950 N ' C�1 UrG�� ��` Lo cll TANK ID # 1 39- 13-2-7- 0) <br /> ANK SIZE 7JGJd UEL TYPE Spii <br /> 11. GENERAL SITE HISTORY <br /> *w <br /> Is permit current? es o ermit # IFacility Status Code tj ( oc.Soil/GW Cont 1Y.S <br /> umber of Tanks at facility t ge of Tanks(if available) Un Le-1 IT ype of Tank ISteel rgl ngl Dual <br /> 111. TANK HISTORY Flen'101i '+• S <br /> as Tank tested? Ifes o ailed precision test ? es I o If yes, give date(s) <br /> Jas a repair made to the tank system? Yes No yes, what was repaired? <br /> ns repair done under inspection?Fes 4o ere soil samples analyzed? 1Yes -G TXT -D b/EDB <br /> ype of failure/discharge 7atastrophic long-term leakage verfiIL noun I lo <br /> ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es o epth to Ground Water of/Year (�g(� verage Amual Precipitation = 4 10 25 <br /> -Site Wells) es o umber 8 Type [rr om ub <br /> S Score S Score S Score <br /> istance 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 ondition R condition R ondition <br /> V. Site Feature - Leaching Potential Analysis .� ,3j E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) (� >100 1-100 S jo 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Cl Unknown >resent <br /> verage Annual Precipitation (inches) KXXXXX <10 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 resent <br /> lnique site features: Recharge area, coarse soil, nearby wells. At least lore than <br /> xxxxx None one one <br /> S <br /> COLUMN TOTALS>>>TOTAL POINTS + 3& + <br /> ample Re lt: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> T 3q0 Firm B T I X E B JT X E <br /> X W OO ?Pt+'� MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> -f a� TPH 9o�c IESEI 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 < 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 BTX8E are not applicable at a TPH concentration of 10 ppn (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION IM-2' ND+t' .P'pinS 9f,t! Pve51cr& <br /> 1. Are BTX 8 E or TPN Concentrations > Allowable Levels Yeso fD-(004 &5PC�}Gt wt; bvtl <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation �gp�Nps �p Pr+� <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE fE5 0 EFERRED TO SITE MITIGATION FOR EVALUATION YES JO <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> :VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />