Laserfiche WebLink
SAN JOAOUI ' /NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H DIVISION <br /> I . UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE 7 � � — y r <br /> AME OF FACILITY 1 ECORD IO 3 I <br /> DORE 55 a 1 - ANK ID # 3 - 1 5 _ <br /> TANK SIZE ' (0ODD UEL TYPE U <br /> I1 . GENERAL SITE HISTORY <br /> Is permit current? eso ermit # - scility Status Code oc . Soil /GW Cont es o <br /> umber of Tanks at facility �j ge of Tank ( if available) ype of Tank Leet Fbrgl ngl Dual <br /> 111 , TANK HISTORY <br /> as Tank tested7 as o ailed precision test 7 es 40 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 i 40 ere soil samples analyzed? as X o TXEIm PH- G PH -0 b/EDB <br /> ype of failure/discharge atastrophic long- term leakage verfill known ther: <br /> IV . REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS ) <br /> Soil Samples Received es a cloth to Ground Water % 1) of/Year �� verage Annual Precipitation <br /> On- Site Wells ) as a umber & Type frr I cm I ub <br /> S core Scar S core <br /> istance to Well ( s ) from Tank ft ; ft ; ft C 0 pts C pts C pts <br /> 0 if 0 if 0 f <br /> R ondition R onditi on R ondition <br /> 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- 50L <br /> ractures in subsurface ( applies to foothills or mountain areas ) None Unknown 3resent <br /> verage Annual Precipitation ( inches ) KXXMX <10 9 10- 25 xxxxxx 26- 402 <br /> an-Made conduits which increase vertical migration <br /> f leachate ( i . e . , septic systems , water wells , ponds ) None Unknown resent <br /> pique site features : Recharge area , coarse soil , or wells . At least lore than <br /> (Muncipal =>2000 it ; domestic=>500 ft ; irr/agricultural =present) xxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS + + <br /> ample Result : ( B T X OR E ) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> B T X E B T X E <br /> MAXIMUM ALLOWABLE B - T-X-E LEVELS (PPM ) 1 50 50 50 .3 . 3 1 . i . NAL <br /> ample Result : ASOLINE 1000 100 10 <br /> K A 6 5 ` I AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPN-0 IESEL 10 , 000 1000 100 <br /> OOTNOTES : *" 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 it , 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 BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel ) . <br /> V1 . STAFF RECOMMENDATION/CONCLUSION —}- f ✓ <br /> 1 . Are BTX & E or TPN Concentrations > Allowable Levels Yes o li�/YI CECit-� {i <br /> 2 . Recommend Site Closure as o If Yes , Refer to Site Mitigation for Evaluation <br /> VII . REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR /LEAD SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES O EFERRED TO SITE MITIGATION FOR EVALUATION ES O <br /> ATE REFERRED ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR ( Y <br /> EH 23 80 (UGTWKSHT ) \5/94 - <br />