Laserfiche WebLink
NT <br /> I. SAN JOi y UGST WORKSHEETA <br /> AFOR SITEICLOSUREIEVALUAT�ExuTH DIVISION ATE <br /> AME OF FACILITY // ,��< SWEEPS CODE <br /> DRESS �(� S /l(��.,� (/ TANK 10 it <br /> ANK SIZE I _5('_)0 UEL TYPE �G <br /> II. GENERAL SITE HISTORY <br /> ** <br /> Is permit current? es o ermit # - acility Status Code oc.Soil/GW Cant es o <br /> umber of Tanks at facility kge of Tanks(if available) ype of Tank Isteet I lFbrgi I Isngl I Dual <br /> III. TANK HISTORY <br /> Jas Tank tested? es o ailed precision test ? FT77go If yes, give date(s) <br /> as a repair made to the tank system? Yes No f yes, what was repaired? <br /> Jas repair done under inspection? es go Jere soil samples analyzed? Ires I Igo PH-G PH-0ype of failure/discharge atastrophic long-term leakage verfill nown jtheTXE <br /> : <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/Yeaverage Annual Precipitation = 4 0-25 <br /> -Site Wells) es o umber & Type Irr om ub <br /> S Score S Score S core <br /> Distance to WeIL(s) from Tank ft; ft; ft C 10 pts C 9 pts C pts <br /> 0 if 0 if 0 f <br /> R rondition R condition R ondition <br /> 1. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 G 25-501 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) xxxxxx <10 9 10-25 Kmxxxx 26-40�L2 <br /> an-Made conduits which increase vertical migration WCIA a'1 <br /> f leachate (i.e., septic systems, water wells, ponds) r1-_c /0 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 Z + + O 3 <br /> Sample Rest: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or-fess <br /> 8 1 T X E X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .373, 1. 1. / NAL <br /> ample Result: LINE 1000 0 10 / <br /> jlip W4AXIMUM ALLOWABLE TPN LEVELS (PPM) <br /> (� ! (1 TPM rIESEL 10,000 1000 \ 100 / <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the leachi tential <br /> analysis. (i.e., site is cuttentty-crt�l 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, scor poen s. <br /> \3 Levels for 8TX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure es Igo <br /> If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SEN10R <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE fES INO <br /> EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED DATE CLOSURE LETTER MAILED <br /> AME OF ' <br /> VALUATORCs� R <br /> EH 23 80 (UGTWKSHT)\5/9(Y <br />