Laserfiche WebLink
SAN JOA1QUJ0 TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H DIVISION <br />UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br />AME OF FACILITY ECORD ID —3 I 4F 1 <br />DDRESS / O /� L� ANK ID # <br />TANK SIZEUEL TYPE ` ,(_ (IL- <br />[I. GENERAL SITE HISTORY \ _ U /✓ <br />permit current? es o x ermit # - acility Status Code I ID <br />oc.Soil/GW Cont es o <br />nber of Tanks at facility ge of Tank(if available) I 6a_ ype of Tank teel WFbrgl ngl Dual <br />as Tank tested? <br />es <br />o <br />IN01 <br />ailed precision test ? <br />es <br />o <br />If <br />yes, give date(s) <br />k= <br />as a repair made to the tank system? es No 1 <br />11f yes, what was repaired? <br />On -Site Well(s) <br />as repair done under inspection? es No <br />ere soil samples analyzed? <br />es <br />I <br />o <br />TXE I <br />ITPH-GI <br />IT PH -D <br />ub <br />b/ED8 <br />ype of failure/discharge <br />S <br />C <br />0 <br />R <br />E <br />atastrophic <br />long-term leakage <br />3core <br />5 pts <br />if <br />ondition <br />is met <br />verfill <br />ft; ft; ft C <br />0 <br />nknown <br />V. Site Feature - Leaching Potential Analysis E <br />then: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />7 <br />Soil Samples Received <br />es I <br />0 <br />IN01 <br />0 <br />epth to Ground Water <br />of/Year <br />/ / <br />verage Annual Precipitation <br />k= <br />4 <br />0-25 <br />On -Site Well(s) <br />Fes <br />I <br />o <br />I <br />umber & Type <br />Irr)am <br />ub <br />S <br />Score <br />10 pts <br />if <br />condition <br />is met <br />S <br />C <br />0 <br />R <br />E <br />Score <br />9 pts <br />if <br />condition <br />is met <br />S <br />C <br />0 <br />R <br />E <br />3core <br />5 pts <br />if <br />ondition <br />is met <br />istance to Well(s) from Tank <br />ft; ft; ft C <br />0 <br />R <br />V. Site Feature - Leaching Potential Analysis E <br />inimum Depth to groundwater from the Soil Sample (feet)4r 1 <br />>100 <br />1-100 <br />' <br />25-50L1 <br />Fractures in subsurface (applies to foothills or mountain areas) t A <br />None <br />Unknown <br />resent <br />verage Annual Precipitation (inches) KXXXXX <br /><10 <br />9 <br />10-25 <br />xxxxxx <br />26-402 <br />an -Made conduits which increase vertical migration <br />f leachate (i.e., septic systems, water wells, ponds) 1� <br />None <br />Unknown <br />resent <br />pique site features: Recharge area, coarse soil, or wells. <br />[Muncipal=>2000 ft; domestic=>500 ft; irr/agricultural=present] KXXXXXNone <br />At least <br />one <br />4ore than <br />one <br />COLUMN TOTALS»>TOTAL POINTS A 0 <br />+ <br />flay <br />+ <br />I <br />37 <br />ample Result: (B T X OR E) RANGE OF TOTAL POINTS F9 pts or more <br />T X E <br />1 , 3- Q eT X °l MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) 1 50 50 50 <br />41 - 48 pts <br />40 pt or less <br />NAS <br />B <br />.3 <br />JT <br />.3 <br />X <br />1. <br />E <br />1. <br />ample Result: <br />TPH <br />AXIMUM ALLOWABLE TPH LEVELS (PPM) <br />LINE 1000 <br />100 <br />10 <br />LIESEL10,000 <br />1000 <br />100 <br />S: ***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 BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br />G(� <br />1. Are BTX & E or TPH Concentrations > Allowable Levels Yes o r•� <br />2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br />VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR <br />CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE <br />fES <br />0 <br />EFERRED TO SITE MITIGATION FOR EVALUATION fES <br />0 <br />ATE REFERRED <br />/ / <br />ATE CLOSURE LETTER MAILED <br />AME OF <br />VALUATOR <br />EH 23 80 (UGTWKSHT)\5/94 <br />