Laserfiche WebLink
i'3 I <br /> SAN JOAOUI NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL F— TH DIVISION <br /> 1• UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY 1 T f S — SD WEEPS CODE <br /> DRESS jl� SheTANK ID 9 - <br /> ANK SIZE UEL TYPE - <br /> II. GENERAL SITE HISTORY <br /> Is permit current? es o ermit # - acility Status Code oc.SoiL/GW Cont 1Yes o <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tank IsteeL Fbrgl ngl Dual <br /> III. TANK HISTORY <br /> Jas Tank tested? es a ailed.precision test ? es o 1f yes, give dates) '/ / / / <br /> Jas a repair made to the tank system? IYes Na f yes, what was repaired? <br /> Jas repair done under inspection? es 11 NoPere soil samples analyzed? 1Yes I o TX' <br /> PH-G PH-D / b/EDB <br /> ype of failure/discharge atastrophic Long-term leakage verfill nknown they: <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 �j of/Year verage Annual Precipitation <br /> )n-Site Welts) es o umber $ Type ]rr om ub <br /> S Score S cora S core <br /> istance to WeLL(S) from Tank I 2�af- <br /> t; ft; ft C 10 pts C 9 pts C '; pts <br /> 0 if 0 if 0 -f <br /> R ondition R condition R ondition <br /> V. Site Feature - Leaching Potential Analysis E is met E lis met E s met <br /> inimum Depth to groundwater from the Soit Sample (feet) >100 1-100 25-5011 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown aresent <br /> verage Annual Precipitation (inches) xxxx <10 9 10-25 xxxxxxx 25-40L <br /> Ian-Made conduits which increase vertical migration r'� <br /> f leachate (i.e., septic systems., water wells, ponds) [V None Unknown resent ' <br /> pique site features: Recharge area, coarse soil, nearby wells. At Least 4ore than <br /> xxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS Z� + + <br /> ample Result, (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> B I T X E B T X E s <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) .1 50 50 50 .3 .3 1. 1. NA_ <br /> Sample Result: ASOLINE 1000 100 10 i <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH 1ESEL 10,000 1000 100 j <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the Leaching potentiat l <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 /> _\2 If precipitation is,> 40 inches, score 0 points. <br /> ,L3 Levets for BTX$E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION , <br /> IIr <br /> i. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o' <br /> i <br /> 2. Recommend Site Closure IYes o 1 If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMP+LETED BY A SUPERVISOR/ ENIOR " <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES ` 0 I EFERRED TO SITE MITIGATION FOR EVALUATION E5 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILEb <br /> AME OF <br /> VALUATOR <br /> EH .23 80 (UGTWKSHT)\5/ 0 <br />