Laserfiche WebLink
SAN JOS COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTSEALTH DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE I a . g , /p <br /> AME OF FACILITY '4GLV cU-A Ptckt-e.( I WEEPS CODE ZI 6 g <br /> DRESS 0&'f/ZO SCG ej IIJ '�n�f�� '�l [TANK ID k 3�_Z'& � C/ <br /> TANK 512E UEL TYPE Cjje5- <br /> I1. GENERAL SITE HISTORY <br /> Is permit current? es o ermit # IFacility Status Code 5 G oc.soil/GW Con es o <br /> umber of Tanks at facility .>L ge of Tanks(if available) uo4- ype of Tank IS <br /> teal brgl ngL Dual <br /> 111. TANK HISTORY gvAcv',e - L)AV Y1o,-, <br /> Jas Tank tested? as o ai , gi <br /> led precision test 7 es o If yesve date(s) <br /> Jas a repair made to the tank system? as No f yes, what was repaired? <br /> as repair done under inspection? es No ere soil samples analyzed? as �41TXE -G I PH-D EDB <br /> Type of failure/discharge atastrophic long-term leakage verfill I virenown ther: <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 ro of/Year verage Annual Precipitation km 4 0.25 <br /> -Site Wells) es o umber 8 Type Irr om I ub <br /> S Score S Score S Score <br /> istance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R ondition R condition R ondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) C}, fJ,' >100 1-100 25-5011 <br /> i <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown Dresent <br /> verage Annual Precipitation (inches) xxxx <10 9 10-25 xmxxxx 26-4012 <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 4ore than <br /> xxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS P pts or more 41 - 48 pts 40 pts or less <br /> at 4J1J - B i'C 5ppb <br /> 16 i �C •`�ppb = .Do$�,m MAXIMUM ALLOWABLE B-T-%-E LEVELS (PPM) 8 50 50 50 .3 .3 1. 1. NA <br /> be to <br /> Vu ample Result: ASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> 1V D OPPMTPHAteyt IESEL 10,000 1000 100 <br /> GOTNOTES: •"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 /> 11 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 /> 13 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION 'd'C= Svti U-5 C-'oi c C <br /> 41. 222• <br /> 1. Are BTX 8 E or TPH Concentrations ALlouable Levels Yes o TCu bf 00+ bj vyc'_c' 1jV{- SGt <br /> ll'� ���((( 8T-� vr�� stn( T� <br /> I2. Recommend Site Closure ITeS ly ryo I �lf Yes, Refer to Site Mitigation for Evaluation 1C qo� <br /> Vll. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES D EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />