Laserfiche WebLink
SAN JOIIOUINSNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE1 w DIVISION <br /> I' UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY Z lCv (a" , EPS CODE 2069 <br /> DDRESS _ �� ANK ID N <br /> ARK SIZE _,]FUEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> ** <br /> Is Permit current? es o ermit # acility Status Code oc.Soil/GWCont IYes o <br /> umber of Tanks at facility go of Tanks(if available) ype of Tank teel brgl ngl Dual <br /> Ill. TANK HISTORY <br /> as Tank tested? es o ailed precision test ? es o If yes, give dates) / <br /> as a repair made to the tank system? as No f yes, what was repaired? <br /> ns repair done under inspection? 40 are soil samples analyzed? as to TXE PH-G PH-D /EDB <br /> ypo of failure/discharge atastrophic tong-term leakage verfill nown Llother: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es o epth to Ground Water of/Year ; verage Amual Precipitation <br /> -site Wells) eso umbar & Type trr om ub <br /> S core S Score S core <br /> (stance to Wells) from Tank ft; ft; fit C 0 pts C 9 pts C pts <br /> 0 f 0 if 0 f <br /> R ondition R condition R ondition <br /> Site Feature - Leaching Potential Analysis E s met E is met E s met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 25-50\1 <br /> racturea in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 Kxxxxxx 26-40\2 <br /> nn-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water welts, ponds) None Unknown Dresent <br /> lnique site features: Recharge area, coarse soil, nearby wells. At least 4ore than <br /> xxxx None one one <br /> COLUMN TOTALS»)TOTAL POINTS + + <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTSpts or moN 41 48 pts 40 pts or less <br /> B I T X E B T I X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (P ) 1 50 50 150 .3 1.3 1. 1. NA\3 <br /> Sample Result: ASDL El 1000 100 10 <br /> AXIMUM ALLOWABLE TPN LEVELS:(PPM) <br /> TPH IESEL. 10,000 1000 100 <br /> OOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the teaching potential <br /> analysis, (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> \1 If depth is > S ft. and < 25 ft., score 0 points. If depth r_5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100-ppm (diesel). <br /> Vt. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure es o if Yes, Refer to Site Mitigation for Evaluation <br /> V11. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE VES1 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> -VALUATOR <br /> £H 23 BO (UGTWKSHT)\5/90 <br /> Ex 29 80 <br />