Laserfiche WebLink
SAN ,IOAOUI NTY PUBLIC HEALTH SERVICES/ENVIRCNMEHTAL H;+ I DIVISION <br /> FI. <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE =,-T �� <br /> nr�£ aF r:gN <br /> .CEPS �QQE00RESS a51n L n �EL TYPE ) I <br /> r <br /> It. GENERAL SITE HISTORY " <br /> Is permit current7 es a ermit A - aciLity status Code oe.so' /c;w Cant es o <br /> user of tanks at facility ge of Tanks(if available) ype of Tank Leet brgl rgi Duat <br /> fit. TANK HISTORY <br /> ns lank tested? es o ailed precision test ? es o if yes, give date{s) / <br /> as a repair made to the tank system? es a f yes, what was repaired? <br /> 'ns repair done under inspec ion? ere sail samples analyzed? es a T E PH-G PH-0 b/EDB <br /> ype of failure/discharge a a t ophic tang-term leakage verfi[L own [her: <br /> IV. REMOVAL HISTORY (ATTACH THSP CTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oit Samples Received es o epth to Ground Water �C' of/Year Ir :64 verage Annual -Precipitation = 4 0-25 <br /> -Site Wells) es o umber b Type Ire om b <br /> S Score S Score S core <br /> istance to Wetl(s) from Tank tuft; ft; ft C Q pts C P pts C pts <br /> 0 if O if 0 f <br /> R =onditicn R condition R ondition <br /> V. Site Feature - Leaching Potentia[ Analysis E is met E is mei E s met <br /> inimum Depth to groundwater from the Soil Samp[ feet }L C} >100 t-100 25-50\1. <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown Dresent <br /> verage AmuaL Precipitation (inches) Kxxxxx 410 9 10-25 KXXXXXX 26-40\2 <br /> Ian-Made conduits which increase vertical migration <br /> Df leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> pique site features: Recharge area, coarse soil, nearby weds. At Least lore than <br /> xxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS + + <br /> ample Resutt. (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> R Z•L1 r,r 1 0�5 B T X E e T X E <br /> ✓ rV �' MAXiMLH ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Resuit. SOLINE 1000 109 10 <br /> •� IMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> OOTHOTES: ""If documented soil and/or ground water contamination is present, do not complere the teaching potential <br /> analysis- (i.e., site is Currently on UGT Contamination List for soft or ground water.) <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft. §2_Mt use table.' <br /> \Z If precipitation is > 40 inches, score 0 points. - <br /> \3 Levels for BTX&E are not applicable at a TPH concentration of. 10 ppo (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOf41ENDATION/CCNCLUSION <br /> 1. Are BTX & E or TPH Concentrations > ALIv [e Levels Tcs a <br /> 2. Recommend Site Closure es v If Yes, Refer to Site Mitigation for EvaLuation I <br /> i <br /> VII. REVIEW EVALUATION - TO BE CCMPLETED ST A SUPERVISOR/SENICR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE E50 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED f % <br /> 1AME OF <br /> :VALUATOR <br /> I c <br /> CH 23 80 (UGTWK5HT)\5/90 <br /> ice, r, <br />