Laserfiche WebLink
SAN JO'_ 4 COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENT.... dEALTH DIVISION <br /> I• UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE Q a <br /> AME OF FACILITY - CJZ'fti4�, CC7/�• a WEEPS CODE <br /> DRESSMjdANK lD M <br /> TANK SIZE UEL TYPE _ <br /> 11. GENERAL SITE HISTORY <br /> ww <br /> Is permit current7 es o • ermit as - acility Status Code oc.Soi /GW Cont es o <br /> umber of Tanks at facility k9e of Tanks(if available) Type'of Tank teen fbrgl ngl Dual <br /> 111. TANK HISTORY <br /> as Tank tested? es o ailed precision test 7 eso If yes, give date(s) j/ <br /> as a repair made to the tank system? es No I Af yes, what was repaired? <br /> as repair done under inspection) es I No L- ere soil samples analyzed7 o tTXE I PH-G PH-0 I Jb/EDB <br /> type of failure/discharge alastrophic lcng-term leakage verfiti mown they: <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 verage Annual Precipitation <br /> -Site Well(s) es o user 8 Type IrrGm ub <br /> S Score S Score S Score <br /> istance to Welt(s)-from Tank ft; ft; ft C 10 pts C 9 pts C - pts <br /> O if 0 if 0 if <br /> R undition R condition R olidition <br /> J. Site feature - Leaching Potential Analysis E is mkt E is met E is meet <br /> inimrrn Depth to groundwater from the Soil Simple (feet) - >1U0 1-100 25-5U)1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown 3resent <br /> verage Annual Precipitation (inches) xxxx <10 9 10-25 xxxxxxx 26.40L2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> pique site features: Recharge area, coarse soil, nearby wells. At least ore than <br /> xxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS . + <br /> 'ample Result: (B T X OR E) RANGE Of TOTAL POINTS 9 Its or more 41 - 48 pts 40 pts or less <br /> B T X E B T X E <br /> MAXIMUM ALLOWABLE B-T•X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA <br /> l3 <br /> 'ample Result: ASOLINE 1000 100 10 <br /> IMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> UUTNOTES: ***If docunented soil aW/or ground water contamination is present, do not caiplete the leaching 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 rut use table. <br /> 2 If precipitation is > 40 inches, score 0 points. <br /> Ll Levels for BTX&E are not applicable at a TP11 concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPM Concentrations > Allowable Levels Yes o •I <br /> 2. Recontnend Site Closurees o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES U EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> Ell 23 U0 (UGTWKSHT)\5/90 <br />