Laserfiche WebLink
SAN JOAOIIIANTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL *H DIVISION <br /> 1' UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY � / / <br /> WEEPS CODE <br /> DRESS <br /> ANK SIZE UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? es o Is 11 # - acili ty Status Code oc-Soil/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) IType of Tank Leel fbrgl ngl Dual <br /> lll. TANK HISTORY <br /> as Tank tested? es o ailed precision test ) es o If yes, give date(s) <br /> as a repair made to the tank system? as No f yes, what was repaired, <br /> as repair done under inspection? es o ere soil samples analyxed7 es o TxE PN-G PH-D b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfill noun Cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es o epth to Ground Water of/Year /., verage Annual Precipitation = 4 0-25 <br /> n-Site Well(S) es 0 umber 8 Type Irr an ub <br /> S core STce S core <br /> istance to Wells) from Tank ft; ft; ft C 0 pts Cs C pts <br /> 0 f 0 0 fV. R Dodi tion Rition R Dodi tion <br /> Site Feature - Leaching Potential Analysis E is met E et Es met <br /> inimum Depth to groundwater from the Soil Sample (feet); >100 1-100 25-501 <br /> Fractures in -- - <br /> subsurface (applies to foothills or mountain areas) " , None Unknown >resent <br /> verage Annual Precipitation (inches) xxxx <10 9 10-25 xmxxxx 26-40L <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> nique site features: Recharge area, coarse soil, nearby wells. At Least ore than <br /> xxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS + -� <br /> ample Result: (B T % OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> BT % E B T % E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) <br /> 1 50 50 50 .3 .3 11. 1 1. NAS <br /> Sample Result: SOLINE 1000 100 10 <br /> I ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> OOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the leaching potential <br /> arelysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> L If depth is > 5 ft, and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> L If precipitation is > 40 inches, score 0 points. <br /> L Levels for BTXBE are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o <br /> 17 <br /> 2. Reconmerd Site Closure Yes p,,-�No I �*If Yes, Refer to Site Mitigation for Evaluation <br /> Vil. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 10 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />