Laserfiche WebLink
J - <br /> r f <br /> SAN 10ACUIN CCL( ILIO HEALTH SERVICES/E4VIRCNME4TAL HEALT# ..iCN <br /> UGsi ,URKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> MA ME OF FACILITY I rr / �� 4 FWFEPS CODE LCL a/J/ <br /> ()DRESS �� 7 ,S <br /> ANK ID x <br /> [ANY SIZE / UEL TYPE ^ <br /> 11. GENERAL SITE HISTORY <br /> Is permit current7 es o V ermit ;9 I - acility Status Code oc.Soil/GW Conc es o <br /> uanber of Tanks at facilityge of ianks(if available) 6L L'4 ype of Tank Leel Fbrgl N L Dual <br /> Ill. TANK HISTCRY <br /> ns Tank tested? es o �/ ailed precision test ? es o If yes, give date(s) <br /> as a repair ,rade to the tank system? es 4o f yes, what was repaired? F <br /> 'ns repair done under inspection7 esof ere soil samples analyzed? es o TXE PH-G FT PH-0 b/ED8 <br /> irype of failure/discharge atastrophic long-term leakage verfiII known I lather: <br /> IV. REMOVAL HISTORY(ATTACH INSPECTION REPORT FCR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samoles Received 1 es o epth to Ground 'Dater 1fj of/Tear 3rP ver age Annual Precipitation - 4 0-25 <br /> List <br /> Jell s) es o ✓ ember b Type Irr cm ub <br /> S core S core S care <br /> e to Well(s) from Tank ft; ft; ft C 10 pts C 9 pts C pts <br /> 0 if 0 if 0 if <br /> R condition R condition R condition <br /> Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimtm Depth to groundwater from the Soil Sample (feet) �lp_l�=a >100 1-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) O .4 on Unknown resent <br /> %vcrage Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> an-made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> niGue site features: Recharge area, coarse soil, nearby wells. At least ) are than <br /> xxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS D * ' S <br /> ample <br /> /Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> /�JB 1 T X E 8 JT X E <br /> MAXIMLH ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. 4A\3 <br /> Sample Result: ASOLiNE 1000 100 10 <br /> ��� �, AX1At1M ALLOtNABIE TPH LEVELS (PPM) <br /> TPH 31ESEL 10,000 1000 100 <br /> COT40TES: ***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 ppn (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECCh4iENDATION/CONCLUSIO9 <br /> 1. Are 3TX S E or TPN Concentrations > Allowable Levels Yes o 7��m• <br /> 2. Recommerd Site Closure 'Yes o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATICN - TO BE CCHPLETEO BY A SUPERVISCR/SE41OR <br /> CONCUR LITH STAFF RECOMMENDATION FOR CLOSUREES0 EFERREO TO SITE MITIGATICH FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> JAME OF <br /> :VALUATCR <br /> EN 23 80 (UGTVKSHT)\5/90 <br />