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SAN JOA COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTOALTH DIVISION <br /> I' UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> ATE <br /> AME OF FACILITY 77 <br /> WEEPS CODE <br /> DRESS Zo V I_Q� ARK ID # <br /> 39 oio 3 <br /> TANK 512E (� �b DEL TYPE I <br /> II. GENERAL SITE HISTORY i d <br /> Is permit curren[T es o <br /> ermit # aciliTy Status Code _--� oc.Soil/GW Cont es o <br /> umber of Tanks at facility Be of Tanks(if available) �. ype of Tank teelFbrgl ngl /,.Dual <br /> III. TANK HISTORY <br /> Mtested? es okaiprecision test 7 es yes, give da te(s) /e to the tank es No f yes, what was repaired? <br /> nder inspec[i o ii%E PH-G PH•D h/EDB <br /> ischarge ic long-term leakage verfill known ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es o epth to Ground Water of/Year verage Annual Precipitation = 4 0-25 <br /> n-Site Wetl(s) es I o umber 8 Type Irr I an I ub <br /> istance to WeLL(S) from Tank S core S core S core <br /> ft; ft; ft C 0 pts C pts C pts <br /> 0 if O f 0 f <br /> Site Feature - Leaching Potential Analysis R onditi on R oditi on R ordition <br /> E is met E is met E is met <br /> inifium Depth to groundwater from the Soil Sample (feet) >100 1-100 <br /> 25-50� <br /> ractures in subsurface (applies to foothills or mountain areas) None <br /> - Unknown resent <br /> verage Annual Precipitation (inches) xxxxx <10 9 10-25 xxxxxx 26-4012 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown <br /> resent, <br /> nique site features: Recharge area, coarse soil, nearby wells. At least ore than <br /> xxxxx None <br /> 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 /> -Oslo X <br /> 6-� G B MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 150 50 50 .3 .3 1. 1. NAL3 <br /> ample Result: ASOLINE 1000 100 10 <br /> AXI MUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH 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 ft. 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 /> 1 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes 0 <br /> 2. Recommend Site Closure es If Yes, Refer to Site Mitigation for Evaluation _ <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> i <br /> CONCUR 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 <br /> EH 23 80 (UGTWKSHT)\5/90 <br />