Laserfiche WebLink
SAN NTY PUBLIC HEALTH SERVICES/EHVIR FAL H DIVISION <br />i, UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE1-7-32-24 <br />NAME <br />.. (— <br />NAME OF FACILITY- f " % .�.► , <br />SWEEPS CODE r 7" <br />ADDRESS y� GTANK ID #! L <br />TANK SIZE FUEL TYPE i° G <br />it. GENERAL SITE HISTORY <br />Is permit current? Yes No Permit 9I - 'Facility Status Codel IDoc.Soil/GW Cont Yes INo <br />Number of Tanks at facility Age of Tanks(if available)l Type of Tank ISteel l Fbrgl ISngII Dual <br />III. TANK HISTORY <br />Was Tank tested? Yes <br />INo Depth to Ground Water IRef/Year Ave Annual Precipitation <br />No IFailed precision test ? Yesl <br />Noi fIf yes, give date(s) <br />On -Site Well(s) Yes INo!Number & Typal <br />Was a repair made to the tank system? Yes <br />No Iif yes, what was repaired? <br />Was repair done under inspecLiaYd <br />Yes <br />No Were soil samples analyzed?Yes! INog <br />BTXE' �TPH-G� TPH-i8 I Pb/EDB! <br />Type of failure/discharge <br />catastrophic <br />long-term leakage `overfill { f Iother: <br />IV. REMOVAL HISTORY (ATTACK INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />Soil Samples ReceivedIYes <br />INo Depth to Ground Water IRef/Year Ave Annual Precipitation <br />A= 14 <br />10-25 <br />On -Site Well(s) Yes INo!Number & Typal <br />I Irrl Oom <br />Pub` <br />S <br />Scare <br />10 pts <br />S <br />C <br />Score <br />9 pts <br />S <br />C <br />Score <br />5 pts <br />Distance to Wells) from Tank ft; ft; ft C <br />O <br />if <br />condition <br />is met <br />0 <br />R <br />E <br />if <br />condition <br />is met <br />0 <br />R <br />E <br />if <br />conditian <br />is met <br />R <br />V. Site Feature - Leaching Potential Analysis E <br />(Minimum Depth to groundwater from the Soil Samoke (feet) <br />>100 <br />I <br />151-100 <br />I <br />25-50\1 <br />,Fractures in subsurface (applies to foothills or mountain areas) <br />! <br />I <br />I <br />(Present <br />Average Annual Precipitation (inches) xioaxx <br /><10 <br />9 <br />j 10-25 <br />Ixx== <br />26-40\2 <br />Man -Made Conduits which increase vertical migration <br />{ <br />I <br />{ <br />of Leachate (i.e., septic system, water wells, ponds) <br />� <br />Present <br />! <br />?Unique site features: Recharge area, coarse soil, nearby wells. <br />i <br />At least <br />{ <br />More than <br />4 <br />xx <br />None1 <br />Me <br />one <br />1OTALS»>TOTAL POINTS <br />Sample Result: (3 T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 4a pts <br />40 ats or less <br />�X w <br />3� <br />MAXIMUM ALLOWABLE 3 -T -X -E LEVELS (PPM) 50 50 SO .3 J. I i_ 1. <br />NAU' <br />Sample Result: <br />GASOLINE low 100 <br />10 <br />MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br />'DIESEL 10'WO I 1000 <br />I 100 <br />TPH <br />FOOTNOTES: *"Y f d=xwmed soil and/or ground water contamination is present, do not complete the Leaching potential <br />analysis. (i.e., site is currently on UST Contamination List for soil or ground water.) <br />\1 if depth is > 5 ft. and < 25 ft., score 0 points. If depth o=5 ft., do not use table. <br />\2 if precipitation is > 40 inches, score 0 points. <br />\3 Levels for 3TX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br />Vt. STAFF RECOMMENDATION/ ION <br />1. Are 3TX & E or TPH Concentrations > Allowable Levels 'Yes Noj <br />2. Recommend Site Closurelyesi No *If Yes, Refer to Site Mitigation for Evaluation <br />VII. REVIEW EVALUATION - TO 3E COMPLETED 3Y A SUPERVISOR/SENIOR + ( s® <br />CONCUR WITH STAFF RECOMMENDATION FOR CLOSUREfYESI (NOS (REFERRED TO SITE MITIGATION FOR EVALUATION! YES lw! <br />DATE REFERRED ! A DATE CLOSURE LETTER MAILED# <br />NAME OF <br />EVALUATCRI <br />=ii 23 30 (UGTWKSHT)\5/90 <br />