Laserfiche WebLink
SAN JOA0UIIkW6JNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL Ht>w*d"H DIVISION <br /> 1 UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> L4z_1 3 c Z <br /> AME OF FACILITY C� ZSWEEPS CODE Cyd <br /> DDRESS -� , �f� TANK ID # <br /> TANK SIZE ? w UEL TYPE wf <br /> OG <br /> It. GENERAL SITE HISTORY <br /> ww <br /> Is permit current? es o lx�ermit # acuity Status Code oc.Soil/GW Cont es T INO <br /> umber of Tanks at facility �) � ge of Tanks(if available) ype of Tank teeE Fbrgl ngl Dual <br /> III. TANK HISTORY <br /> as Tank tested? eso o ailed precision test ? es If yes, give date(s) G1/ S`/ <br /> as a repair made to the tank system? Yes XNof yes, what was repaired? / F„Y <br /> as repair done under inspection7 es o ere soil samples analyzed? es Io TXE PH-G PH-D b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfill nknown �( ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> .oil Samples Received eso epth to Ground Water /o of/Year /yyz verage Annual Precipitation = 4 10 25 <br /> Site Wells) es o A umber 8 Type 11r om Lb <br /> S core S Score 5 icore <br /> istance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 f <br /> V. ondition R ondition R ondition <br /> Site feature - Leaching Potential Analysis R E is met E is met E s met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1.100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) Kxxxxx <10 <br /> Q 10-25 xxxxxxx 26-40\2 <br /> nn-Made conduits which increase vertical migration <br /> f Leachate (i.e., septic systems, water wells, ponds) None Unknown Dresent <br /> Inique site features: Recharge area, coarse soil, nearby wells. G` At least iore than <br /> xxxxx None one one <br /> COLUMN TOTALS>>TOTAL POINTS ZU + �5 + O <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> 6 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\3 <br /> Sample Result: ASOL(NE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH 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 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 BTXBE are not applicable at a TAH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION ^j'j-z / f 6 -24 fly <br /> f <br /> 1. Are BTX $ E or TPH Concentrations > Allowable Levels Yes o (�(a (, (,1a4eO s ,D l�e� <br /> �( <br /> 2. Recoomend Site Closure es o if Yes, Refer to Site Mitigation for Evaluation J <br /> Edo/0 b w w ydci�cs :t— <br /> Vil. REVIEW EVALUATION - TO BE CCIIPLETED BY A SUPERVISOR/SENIOR {"e ode g <br /> .ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES JO <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF L <br /> r� / <br /> .VALUATOR � �� v <br /> EH 23 80 (UGTWKSHT)\5/90 Qj <br /> EH 29 80 i A� <br />