Laserfiche WebLink
P V1� lqs"se,-- \/a <br /> SAN JOAOU .OUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL LTH DIVISION <br /> I UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE 13 <br /> NAME OF FACILITY $�E LQ u IS 6 L 1 SWEEPS CODE J <br /> ADDRESS TANK ID # <br /> (TANK SIZE FUEL TYPE ' <br /> Ii. GENERAL SITE HIST RY *** <br /> Is permit current? Yes No Permit # - Facility Status Code �1 Doc.Soil/GW Cont Yes No <br /> Number of Tanks at facility 3 Age of Tanks(if available) L� Type of Tank Steel Fbrgl Sngl Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test ? Yes No If yes, give date(s) <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? <br /> .las repair done under inspection? Yes No Were soil samples analyzed? Yes No BTXE TPH-G TPH-D Pb/EDB <br /> Type of failure/discharge catastrophic long-term leakage overfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) n <br /> EE <br /> les Received Yes No Depth to Ground Water `d Ref/Yrcondition <br /> Annual Precipitation A= 14 10-25 <br /> ells) Yes No Number, & Type Irr Dom Pub Score S Score <br /> Distance to Wells) from Tank ft; ft; ft 9 pts C 5 pts <br /> if 0 if <br /> R condition R condition <br /> E is met E is met <br /> IV. Site Feature - Leaching Potential Analysis <br /> Minimum Depth to groundwater from the Soil Sample (feet) >100 51-100 25-50\1 <br /> (Fractures in subsurface (applies to foothills or mountain areas) None Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> i <br /> Man-Made conduits which increase vertical migration None Unknown Present <br /> of leachate (i.e., septic systems, water wells, ponds) <br /> !Unique site features: Recharge area, coarse soil, nearby wells. At leastMore than <br /> ) <br /> xxxxxx None one one <br /> t� 4—re4l <br /> + o - <br /> COLUMN TOTALS»>TOTAL POINTS -Sample Result: (B T XOR E) RANGE OF TOTAL POINTS 49 pt - 48 pts I 40 pts or less� AO �t"� B TT X E! 1– 4I - m MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 53 1. 1. NA\3Sample Result: GASOLINE 100 10MAXIMUM ALLOWABLE TPH LEVELS (PPM)TPH DIESEL 11000 100FOOTN F S: ***If documented soil and/or ground water contamination is , mplete the leaching t' <br /> QMCj MTpri analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> TU �" \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth ­5 ft., do not use table. <br /> IM \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTX&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 �) No <br /> 2. Recommend Site Closure Yes No *If Yes, Refer to Site Mitigation for Evaluation <br /> V:I. REVIEW EVALUATION TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / / l_ L� DATE CLOSLRELETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />