Laserfiche WebLink
SAN JOAOUTATY PUBLIC HEALTH SERVICES/ENVIRONMENTAL �0IVISION <br /> f. UGST 'WORKSHEET FOR SITE CLOSURE EVAALUATION DATE <br /> NAME OF FACILITYs to G 1<L0,T,;,j4 " ^ 91 E4 S�L�-k/iTiit� Ra (GQ SWEEPS CODE 3 / a <br /> A00RES5 ` (TANK 10 (� .9 - 7� -611ANK SIZE / `� FUEL TYPE Qi 6 <br /> I1. GENERAL SITE HISTORY <br /> � I <br /> Is permit current? Yes Na Permit l` - Facility Status Code © OoC.SaiL/Gil Cont Yes Na <br /> Number of Tanks at facility (Age of Tanks(if avaitabte) l Type of Tank ISteet FbrgLI Sngl Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test ? Yes INo If yes, give date(s) <br /> Was a repair made to the tank system? Yes NoI If yes, what was repaired?( <br /> Was repair done under- inspection? Yesl No Were sail samples anatyzed7 Yesl Na BTXEI TPN-GI TP14-0I Pb/EDGI <br /> Type of faiture/discharge catastrophic tong-term teakage overfill unknown Iother: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Sail Samples Received Yes No IDepth to Ground Water Q Ref/Year Average Annual Precipitation A= 14 10-Z5 <br /> On-Site WeM s) Yes No Number & Type Irr. Dam Pub <br /> S Scare S Score S Score <br /> Distance to WeLL(s) from Tank f ft; ft; ft C 10 pts C 9 pts. C 5 pts <br /> a if a if a if <br /> 'R car7dition R condition R condition <br /> V. Site Feature - Leaching_Patentiai Analysis E is met E is met E is met <br /> (Minimum Depth to groundwater from the Soil Sample (feet) _ '100 I5)-100 125-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) I None I Unknown 3I (Present <br /> Average Annual Precipitation (inches) xxxxxxl. <10 I 9 10-25 Ixicx�= 2,6-40\2 <br /> Man-Made conduits which increase vertical migration i 4— <br /> of leachate (i.e., septic systems, water wells, ponds) Hone Unknown Present <br /> IklUnique site features: Recharge area, coarse sail, nearby wells. `{ At least More than <br /> ==XXX None k ane one <br /> COLUMN TOTALS»'TOTAL POINTS + I + V a 3U <br /> Sample Result: (S T X OR E) RANGE OF TOTAL POINTS 49 pts .or more I 4i - 4B. pts <br /> T- <br /> e I T % E B JT X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50� 5o .3 .3 1. 1. NA\3 <br /> 5ampte Rees��ut�DD GASOLINE 1000 100 I 10 <br /> Z <br /> 1 MAXIMUM ALLOWABLE TPH LEVELS (PPM). <br /> �TPH DIESEL 10,000 1000 100 <br /> FOOTNOTES: *"'if documented soil and/or grawsd water cantaminatian is present, do not complete the ing potential <br /> analysis. (i.e., site is currently an UGT Contamination List for sail or ground <br /> \1 If depth is > 5 ft. and < 25 ft., scare 0 paints. If depth CW5 ft., do rat use table- <br /> %2 If precipitation is > 40 inches, scare 13'points- <br /> \3 Levels for BTX&E are not applicable at a TPN concentration of 10 ppm (gasoline) or 10D ppm Cdiesel . <br /> VT. STAFF RECOMMENDATION/CONCLUSION S tDC�C i I t°. f c -1' ! B, a D d + 7 J'-H.D 450 <br /> 1. Are 9TX & E or TPH Concentrations > Allowable Levels '(*Yes No. <br /> s�leP; +� i rP�D <br /> 2. Recommend Site Closure Yesl No If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED aY A SLIPEtVIS/�ENTOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSUREIYES I No IREFL:RREO TO SITE MITIGATION FOR EVALUATION IYE5 HOI I � <br /> DATE REFERREDI / 5--/ 66) (DATE CLOSURE L---TTER MAILED <br /> NAME OF <br /> EVALUATOR( <br /> :H 23 80 (UGTWKSHT)\5/90 W <br /> t <br /> i <br /> i <br />