Laserfiche WebLink
WSAN JOAOUIN C PUBLIC HEALTH SERVICES/ENVIRQNMENTAL JIff DIVISION <br /> I UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY S I!: o SWEEPS CODE <br /> ADDRESS � TANK 10 # - �rJOlpOlo� <br /> TANK SIZE FUEL TYPE �! Oma <br /> II. GENERAL SITE HISTORY <br /> Is permit current? Yes 01 1 <br /> Permit # - Facility Status code Doc.SoiL/GW Cont Yes No <br /> Number of Tanks at facility �\\ Age of:T:a�nk:,:(:ff available) Fype of Tank Steel Fbrgl Sngl Dual <br /> III. TANK HISTORY <br />�r <br /> Was Tank tested? Yes No Failed precision test ? Yes No If yes, give dates) <br /> I <br /> Was a repair made to the tank system? Yes No If yes, what was repaired p <br /> Was repair done under inspection? Yes No Were soil samples analyzed? Yes No B7XE TPH-G TPH-D Pb/EDB <br /> Type of failure/discharge catastrophic long-term leakage overfill unknown other: <br /> !V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LiEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yesj,/ No Depth to Ground Water Ref/Year Average Annual Precipitation A= 14 10-25 <br /> On-Site Welt(s) Yes No Number & Type Err Dom Pub <br /> S Score t{ S Score S Score <br /> Distance to Wells) from Tank ft; ft; ft C 10pts '� C 9 pts C 5 pts <br /> 0 i�f 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) >100 /�� 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) Hone V Unknown Present r <br /> Average Annual Precipitation (inches) xxxxxx 110 t 9 10-25 xxxxxxx 26-40\2 <br /> M <br /> k Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) None s Unknown S Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. i? At least More than <br /> xxxxxx None \ one one <br /> COLUMN TOTALS>>>TOTAL POINTS 3-3 <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more p 41 - 48 pts 40 pts or less t <br /> B T X E B TX E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50j .3 .3 1. NA\ <br /> Sample Result: _ GASOLINE 1000 i 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH DIESEL 10,000 100 <br /> i <br /> FOOTNOTES: *{*If documented soil and/or ground water contamination is present, do complete the leach ial <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 BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> STAFF RECOMMENDATION/CONCLUSION I <br /> I� � I, I <br /> 1. Are BTX & E or TPH Concentrate s > Allo ble Levels •Yes No <br /> i <br /> 2. Recommend Site Closure Yes V1 1 No *Ef Yes, Refer to Site Mitigation for Evaluation ; <br /> I. REVIEW EVALUATION - To BE COM ETED BY A SUPERVISOR/SENIOR Jj <br /> � 3 <br /> COHCUR�WITH STAFF RECOMMENDATION FOR CLOSURE YES NQ 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 />