Laserfiche WebLink
SAN J 'N <br /> COUNTY PUBLIC HEALTH SERVICES/eWTAOHMEN"'I 'teALTH DIVISION <br /> I UST 161gRKSHEET FOR SITE CLOSURE E'IALUATI 00 ATE <br /> AME Of FACILITY1 <br /> 7 ,�1 � �- � � �� 14 i <br /> DDRESS 7 7!' C. V I r .; � ; AHK ID t? - <br /> ANK srzE L TYPE <br /> 1 D i w T bt,�- <br /> Ir. GENERAL SITE HISTORY <br /> Is permit current? es a ermit 2 - aciLity Status Code oc.Sail/G12 Cont esEly] <br /> umber of Tanks aC facility ge of Tank(if availabte} ypeof Tank teeE rg! <br /> [II. TANK HISTORY <br /> as Tank tested? es Nfo ailed precision test ? es o If yes, give date(s) <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> as repair done under inspection? es No ere soiL samples anaiyzed7 es o TXE PH-G PH-0 b/ED8 <br /> ype of failure/discharge tastrophic fang-term leakage verfi[[ ther- <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> EL Samples Received es a epth to Ground Water ef/Year verage Annual Precipitation L= 4 0-25 <br /> -site VelI(sTe s a r & Type Irr Cm <br /> S care 5 care S care <br /> istance to uett(s) from Tank ft; ft; ft C 0 pts C pts C pts <br /> O f O if 0 f <br /> R ondition R ondition R ondition <br /> Site Feature - leaching Potential Armiysis E s met E is met E s met <br /> inimum Depth to groundwater from the Sail Samote (feet) ( >100 1-100AV Q 1 25-301.1 <br /> rac,ures in subsurface (applies to foothills or mountain areas) None Unknown Present <br /> verage annual Precipitation (inches) <10 9 10-25 xxxxxxx 26-4012 <br /> an-Made conduits which increase vertical migration <br /> f teachate (i.e., septic systems, water welts, ponds) None Unknown resent <br /> nicue site features: Recharge area, coarse snit, or wells- At Least 4cre than <br /> (Muncipat=?2000 ft; domestic-->500 ft; irr/agricuituraL=present! None one one <br /> COLUMN TOTALS»>TOTAL POINTS <br /> ampte Result: (S T X OR E) RANGE OF TOTAL POINTS 9 pts a more 41 - 48 pts 40 pts or Less <br /> B F X E B T X E <br /> MAXIML34 ALLOWABLE a-T-X-E LEVELS (PAM) 1 5a 50 50 .3 T. 1 1. NA,L3 <br /> ample Result: LINE i�0 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPF4) <br /> TPH IESEL 10,000 1000 100 <br /> 007NOT ES: *" If docuunnted soiL and/or ground water contamination is present, do not camptete the Lea potent- <br /> analysis. (i.e_, site is currently Orr UG7 Contamination List for sail 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 /> L If precipitation is > 40 inches, scare 0 points. <br /> \3 Levels for BTX&E are not applicable as a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMNENOATION/CONCLUSIOH <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels es o <br /> 2. Recommend Site Ctasure es o If Yes, Refer to Site Mitigation for Evaluation <br /> V11. REVIEW EVALUATION - TO aE COMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE fESJ EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED PATE CLOSURE LETTER MAILS <br /> AME OF <br /> VALUATOR <br /> -_H 23 (30 (UGTWKSHT)\5/94 <br />