Laserfiche WebLink
SAN 10n._..111 COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENT..- HEALTH DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> A <br /> AME OF FACILITY WEEPS CODE G <br /> DRESS n TANK ID <br /> /y V <br /> LANK SIZE UEL TYPE/ate <br /> 11. GENERAL SITE HISTORY J <br /> ,r• <br /> Is permit current? es IN. <br /> V; ermit # - acility Status Code oc.S yyI/GW Cont IYes o <br /> umber of Tanks at facility ge of Tanks(if available) Type'of Tank ISteel VFbrql ngl Dual <br /> 111. TANK HISTORY <br /> Jas Tank tested? es o ailed precision test 7 es o If yes, give date(s) <br /> Jas a repair made to the tank system? Yes No 11f yes, what was repaired7 <br /> as repair done under inspection? es NO ere soil samples analyzed? es o ITXE PH-G PH-D b/EDB <br /> type of failure/discharge atastrophic lung-term leakage verfill known locher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es IHOI epth to Ground Water of/Year verage Annual Precipitation = 4 0 25 <br /> Site Well(s) es o umber 1i Type Irr om ub <br /> S core S core S core <br /> istance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C i pts <br /> - 0 if 0 if 0 if <br /> R condition R condition R ondition <br /> V. Site Feature - Leaching Potential Analysis E is mx:t E is met E is met <br /> inimun Depth to groundwater from the Soil Sample (feet) >1UU 1-100 25-5011 <br /> fractures in subsurface (applies to foothills or mountain areas) None Unknown 3resent <br /> verage Annual Precipitation (inches) xxxx <10 9 10-25 xxxxxxx 26-4OL2 <br /> an-Made conduits which increase vertical migration <br /> Df 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 one one <br /> COLUMN TOTALS»>TOTAL POINTS + + <br /> 'ample Result: (B T X OR E) RANGE Of TOTAL POINTS F9 pts or more 41 - 48 pts 40 pts or less <br /> B 1 T X E B JT X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA13 <br /> Sample Result: GASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPN LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> FOOTNOTES: ***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 /> 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 /> L Levels for BTXBE are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION ,. <br /> 1. Are BTX B E or TPN 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 ES I INO EFERRED TO SITE MITIGATION FOR EVALUATION fES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> =VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />