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SAN JOA P COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTA4EALTH DMS 0 <br /> 1' AME OF FACILITY q1UGST WORKSHEET FOR SITE CLOSURE EVALUATION 1 N <br /> ATE �—�-, � <br /> WEEPS CODE O r <br /> DRESS ANK ID # 'Z <br /> �9 <br /> TANK SIZE � iol� -3U UEL TYPE f <br /> 11. GENERAL SITE HISTORY ui��j <br /> CCCJJJIII///JJJYL i <br /> Is permit current? es / o ermit # - <br /> stili ty Status Code i. � oc.Soil/GW Cont es o <br /> umber of Tanks at facilityge of Tanks(if available) " <br /> � , ype of Tank [eel �Fbrgl ngl Dual <br /> 111. TANK HISTORY <br /> as Tank tested? as o ailed precision test 7 es o If <br /> yes, givejdate(s;) /as a repair made to thetank system? es No f yes, what was repaired? <br /> as repair done under inspection? es PH-G PH-D b/EDB <br /> Type of failure/discharge <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 O ; verage Annual Precipitation <br /> )n-Site Welt(s) es o umber 8 Type Irr am ub <br /> istance to Wells) from TankS core S core S core <br /> ft; ft; ft C 0 pts C pts C pts <br /> 0 if 0 if 0 f <br /> ondition <br /> Site Feature R onditi on R R ondition Leeching Potential Analysis E is mist E is mist E <br /> s net <br /> inimaun Depth to groundwater from the Soil Sample (feet) >700 <br /> 1-100 25-5011 <br /> ractures in subsurface (applies to foothills or mountain areas) .: None <br /> Unknown resent <br /> verage Annual Precipitation (inches) xxxxx <10 <br /> 9 10-25 xxxxxx 26-COL <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic system, water wells, ponds) None C� <br /> unknown resent- <br /> nique site features: Recharge area, coarse soil, nearby wells. <br /> , at least ore than <br /> xxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS / r l�: <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9P <br /> gis or more 41 - 48 pts 40 pts or less <br /> MAXIMUM ALLOWABLE B-T-%-E LEVELS (PPM) 8 T X E1 50 SO 50 3 3 1. 1. NAJ3 <br /> ample Result: ASOLINE 1000 100 <br /> 2 AXIMUM ALLOWABLE TPH LEVELS (PPM) 10 <br /> TPH IESEL 10,000 1000 100 <br /> OOTNOTES: ***If documented soil and/or ground water contamination is present, do not ¢anplete the Leaching potential <br /> analysis. (i.e., site is currently on UGT Contamirw tion 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 /> 1 If precipitation is > 40 inches, score 0 points. <br /> L Levels for BTXBE are not applicable at a TPH concentration of 10 PPI (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 eso moi, If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 I 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 />