Laserfiche WebLink
SAH JOAOUM C 7 PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL FgS DIVISION j <br /> 1• UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE 2 2 <br /> AME OF FACILITY N r WEEPS CODE �SO <br /> DDRESS 16f nlkrg- r ANK 1 D # <br /> ARK SIZE 1 ,5,060UEL TYPE <br /> 1I. GENERAL SITE HISTORY <br /> t* <br /> Is permit current? as o ermit !! - aci[ity Status Code oc-Soi[/GW Cont IYes T7T- <br /> qumber of Tanks at facility Age of Tanks(if available) V� ype of Tank teeE Fbrgl ,D <br /> ngl ual I` <br /> 111. TANK HISTORY <br /> os Tank tested? es INO ailed precision test t es I o It yes, give date s) <br /> Jas a repair made to the tank system7 es Nof yes, what was repaired? <br /> as repair done under inspection7 es o ere soil samples analyzed? es o T PH-G PH-D b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfilt known ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oit Samples Received ea I o epth to Ground Water of/Year f verage Annual Precipitation G 0-25 <br /> Dn-Site Wells) IYes o umber 8 Type trr om ub <br /> S core 5 Score S core <br /> {stance to WeLI(s) from Tank ft; ft; ft C 10 pts C pts C pts <br /> 0 if 0 if 0 f <br /> R ondition R rondition R onditfon +- <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E s met ' <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 25-50i <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 xxxxxxx 26-40i <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e, septic systems, water wells <br /> p YS . ponds) None Unknown 3resent <br /> pique site features: Recharge area, coarse soil, nearby welts. At [east ore than xxxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS + + <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 19 pts or more 41 - 48 pts 40 pts or Less. <br /> B T ' X E 1 <br /> 1 T X 1. <br /> , <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1NA�3 <br /> Sample Result: ASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPN LEVELS (PPM) l <br /> TPH IESEL 10,000 1000 100 3 <br /> OOTHOTES: ***If documented soil and/or ground water contamination is present, do not complete the teaching potential <br /> analysis. (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 /> .V If precipitation is > 40 inches, score 0 points. <br /> L Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX b E or TPN Concentrations > Allowable Levels Yes o <br /> 2. Recoamend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE CC14PLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF,RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE.MITIGATION FOR EVALUATION ES 0 s <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AHE OF <br /> -VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />