Laserfiche WebLink
SAN JOADUINONTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HOH DIVISION <br /> I, UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE 7-6 y r <br /> AME OF FACILITY I (' ECORD ID �-� 3 <br /> DDRESSq75 - ANK ID # 3 - 5 y_ <br /> TANK SIZE IF <br /> UEL TYPE ��l�� � OV ly�'-„ <br /> 11. GENERAL SITE HISTORY M_M ;) <br /> •w <br /> Is permit current? es X o ermit # - acility Status Code oc.Soil/GW Cont as o <br /> umber of Tanks at facility ge of Tank(if available) IType of Tank ISteel Fbrgl HE Dual <br /> 111. TANK HISTORY <br /> as Tank tested? es o IF <br /> ailed precision test ? as o Niff yes, give date(s) <br /> as a repair made to the tank system? Yes No f yes, what was repaired? <br /> as repair done under inspection? es o ere soil samples analyied7 es a TXE PH-G PH-D b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfill nknown ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es o epth toGround Water I iIof/Year verage Annual Precipitation = 4 0-25 <br /> )n-Site Well(s) as o I umber & Type Irr am I ub <br /> S core S Score S Score <br /> )!stance to Wel l(s) from Tank ft; ft; ft C 0 pts C pts C pts <br /> 0 if 0 if 0 if <br /> R ondition R condition R ondition <br /> J. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 25-50_\l <br /> Fractures in subsurface (applies to foothills or mountain areas) /O None Unknown resent <br /> verage Annual Precipitation (inches) KXXUX <10 9 10-25 Kxxxmx 26-40L <br /> Ian-Made conduits which increase vertical migration <br /> Df leachate (i.e., septic systems, water wells, ponds) �� None Unknown resent <br /> pique site features: Recharge area, coarse soil, or wells. At least 4ore then <br /> [Muncipal=>2000 ft; domestic=>500 ft; irr/agricultural=presentl xx+xx None one one <br /> -•i� ' 0 COLUMN TOTALS»>TOTAL POINTS ), 0 * q Q <br /> S Dom-' ample Result: (B T X OR E) D RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> 3 3 = f 7pei t <br /> 1= 33oPP'"' B T X E B T X E <br /> t yYl, MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 3 1. 1. NA�3 <br /> Sample Result: ASOLINE 1000 100 10 <br /> 4,ICC0 prn w— TPH C9— AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> (o TPH 0 IESEL 10,000 1000 100 <br /> OOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the leaching <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 4=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 <br /> 100 ppm (//diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION A �QQ/1aAL e 3Le ppyn <br /> 1. Are STX & E or TPH Concentrations > Allowable Levels Yes o 'r <br /> 2. <br /> 2. Recommend Site Closure as o If Yes, Refer to Site Hi tigation for Evaluation �'e�Z1// Gr C ?./f� <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ESi O EFERRED TO SITE MITIGATION FOR EVALUATION ES O <br /> ATE REFERRED ATE CLOSURE LETTER MAILED / / <br /> AME OF f <br /> VALUATOR <br /> EH 11 10 (UGTWKSHT)\5/94 .. <br />