Laserfiche WebLink
SAH JOAOU%'tOUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> OF FACILITY SSWEEPS CODE 2 <br /> DRESS l� �V 4TANK 11) X - <br /> ANK SIZE UEL TYPE <br /> II. GENERAL SITE HISTORY Q� <br /> s permit current? es o ormit * - ocility Status Code oc.Soit/GW Cont es o <br /> r of Tanks at facility go of Tanks(if available) ype of Tank test brgt I jngt I Dual <br /> 111. TANK HISTORY <br /> Jas Tank tested? es o sited precision test ? es o if yes, give date(s) <br /> s a repair made to the tank system? Yes No f yes, what was repaired? <br /> s repair done under inspection? es o re soil samples analyzed? es o TXE PH-G PH-D b/EDB <br /> ype of failure/discharge tastrophic tong-term leakage verfill nown 10 <br /> ther:Ica <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> it Samples Received as o epth to Ground Water of/Year verage Annual Precipitation - 4 0-25 <br /> -Site Wells) es o r 3 Type 1K11rr om <br /> S Score S Score Score <br /> istance to Watt(s) from Tank ft; ft; ft C 0 pts C pts C pts <br /> 0 if 0 if 0 if <br /> R condition R condition R condition <br /> Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> iniaum Depth to groundwater from the Soil Sample (feet) f(� >100 1-100 25-5011 <br /> lr*actures in subsurface (applies to foothills or mountain areas) None Unknown Present <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 Kxxxxxx 26-4012 <br /> 4an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water welts, ponds) 1 V None Unknown Present. <br /> ique site features: Recharge area, coarse soil, nearby welts. At least 4ore than <br /> Kxxxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS + + <br /> to Rerrsuul�lt: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> 007-m 8 T X E B JT X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA13 <br /> Sample Result: SOLINE 1000 100 10 <br /> N IMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> FOOTNOTES: ***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 /> L If depth is > 5 ft. and < 25 ft., score 0 points. if depth -5 ft., do not use table. <br /> J2 If precipitation is > 40 inches, score 0 points. <br /> 13 Levels for BTXLE are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION ,. <br /> 1. Are BTX i E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure es If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES EFERRED TO SITE MITIGATION FOR EVALUATION ES I 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR 'La <br /> EH 23 80 (UGTWKSHT)\5/90 /�. le r t C e <br /> J 1. <br />