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SAN JOAOUI COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H ALTH DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY ry C WEEPS CODE <br /> DDRESS / �� ,�� G�� �.� E �� ANK ID p <br /> TANK SIZE l�Q� UEL TYPE <br /> 11. GENERAL SITE HI ORY <br /> 19 permit current? es O ermit # IF <br /> acility Status Code oc.5oil/GW Cont 0s 0 <br /> umber of Tanks at facility he of Tanks(if available) I IType of Tank teel Fbrgl I IS <br /> ngl Dual <br /> 111. TANK HISTORY <br /> as Tank tested? es IFailed precision test ? as o If yes, give date(s) <br /> as a repair made to the tank system? es No 1 11f yes, what was repaired? <br /> ns repair done under inspection? es I No ere soil samples analyzed? Fas I to I TXE I PH-G PH-D b/EDB <br /> Type of failure/discharge atastrophic longterm leakage verfill nknown 1 10ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Foil Samples Received as X o I epth to Ground Water _?� of/Yeartit ; F61 verage Annual Precipitation = 4 10-25 <br /> 3n-Site Well(s) es o I umber & Type I Irr I Lm <br /> bb <br /> S core S Score 5 Score <br /> istance to Wells) from Tank ft; ft; it C 10 pts a 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R condition R condition R ordition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 U` 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) JD None Unknown rresent <br /> verage Annual Precipitation (inches) xxxxxx <10 9 10.25 xxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration p' <br /> f leachate (i.e., septic systems, water wells, ponds) None ( Unknown Fresent <br /> Inique site features: Recharge area, coarse soil, nearby wells. Q At least lore than <br /> xxxxx None ( one one <br /> COLUMN TOTALS>>>TOTAL POINTS /Q + O <br /> ample Result: (S T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or less <br /> B T X E 8 T X E <br /> MAXIMUM ALLOWABLE B•T•X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> 100 <br /> Sample Result: ASOI.INE 7000 10 <br /> AXIMUM 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 /> \1 If depth is > 5 ft. and < 25 ft., score 0 points'. If depth <=5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Level sYes 01 1 <br /> 2. Recommend Site Closure eS o I If Yes, Refer to Site Mitigation for Evaluation <br /> V11. REVIEW EVALUATION • TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> .VALUATOR O�(Q <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 �✓vlP c ` <br />