Laserfiche WebLink
SAN JOAOU IN COUN"' p1IBLIC HEALTH SERVICES/ENVIRONMENTAL 4EALT:1 ^ 'n15ION <br /> t. UG ORKSHEET FOR SITE CLOSURE EVALUATION DA7E J _ D <br /> NAME OF FACILITY PO C - (� ,� SUEPS CODE -3 ,? <br /> z <br /> /.. TANK IDB •� <br /> ZE 3 FUEL TYPE bj4.' ' <br /> It. GENERAL SITE HISTORY <br /> Is permit current? Yes 11 No Permit 9 Facility Status Code U 1 Ooc.soil/OW Con[ Yes No <br /> Number of Tanks at facility Age of Tanks(if available) �. Type of Tank SteeLiM Fbrgl Sngl Dual <br /> 111. TANK HISTORY <br /> Was Tank tested? Yes No Fei led precision test 7 Yes No I AIf yes, give date(s) <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? <br /> Was repair done order inapecti en? Yea No HWere soil samples analyzed? Yes EEDiKi <br /> TPH•G TPN-D - Pb/EDB <br /> Type of failure/discharge catastrophic I long-term leakage overfill ur*n other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> fSoiL Samples Received Yes No Depth to Ground Water Ref/Yesr 3� ; Average Annual Precipitation A- 14 10-25 <br /> On-Site Wells) YeaNo Number i Type Irr Dom Pub <br /> S Score 5 Score S Score <br /> Distance to Wells) from Tank y� �Z _ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 it 0 if 0 if <br /> R condition R condition R condition <br /> V. Site Feature - Leaching Potential Analysis E Is met E is met E is met <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) 'I S O more Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10.25 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) Nora Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At Least More than <br /> xxxxxx Nati one u om <br /> COLUMN TOTALS»>TOTAL POINTS / 0 * a • J <br /> Sample Result: IS T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> AAI IV R T X E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> All IV D TPN lIAXIRIM ALLOWABLE TPH LEVELS (PPM) DIESEL 10,000 1000 100 <br /> FOOTNOTES: —If documented soft 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 BTXAE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMEYDAT IOM/CONCLUSION <br /> l'o r1K P l e= /, 7ot,fDl <br /> 1. Are BTX b E or TPH Concentrations > Allwable Levels 'les No Ap,n�7e,-tn/�o%t/.t'r" <br /> 2. Recommend Site Closure Yes Na If Yes, Refer to Site Mitigation for Evaluation Tr Tr � {t �'*�CQJr�10160- <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CCNC'R WITH STAFF RECCMIKENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YESK NO <br /> DATE REFERRED DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 BO (U"SHT)\5/90 <br />