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SAN JOA01PCOUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAOCALTH DIVISION <br /> 1 UGST WORKSHEET FOR SITE CLOSURE EVALUATION �7 <br /> AME OF FACILITY ATE Z' &_ <br /> DRESS <br /> WEEPS CODE /Q ' D <br /> ;.�,LD <br /> CAK� ARK ID N <br /> TANK SIZE 2(7ZSt� UEL TYPE / 3� IOC �� I <br /> R <br /> 11. GENERAL SITE HISTORY <br /> 90 <br /> Is Permit current? es 0 ermit p - ** <br /> 010I pal acility Status Cd.T__ oc.Soi UGu Cant es \ o <br /> umber of Tanks at facility 2 ge of Tanks(if available) <br /> ype of Tank [eel Fbrgl ngl Dual <br /> III. TANK HISTORY 19 <br /> as Tank tested? as 0 ailed precision test ? es <br /> o ._. It yes, give <br /> as a repair made to the tank system? es No <br /> f yes, what was repaired? �✓✓U �+���.,, <br /> as repair done under inspection? es 0 ere soil samples analyzed? es o <br /> TKE PN-G PH•D b/EDB <br /> ype of failure/discharge atastroph is long•term leakage verfill known <br /> that: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> FSamples Received es o epth to Ground Water <br /> of/Year verage Annual Precipitation = 4 0-25 <br /> n-Site WeIL(s) es I o / umber 8 Type Irr am <br /> ub <br /> istance to WeLl(s) from TankS core S core S core <br /> fR ft; ft C '0 Pts C PIS <br /> C pts <br /> O if 0 t <br /> Site Feature - Leaching Potential Analysis R ondltlon R ondltion R ondition <br /> E is met E is met E 's met <br /> iniaun Depth to groundwater from the Soil Sample (feet) <br /> >100 1-100 - " 25-5011 <br /> ractures in subsurface (applies to foothills or mountain areas) None <br /> - Unknown resent <br /> verage Annual Precipitation (inches) <br /> xxxxx <10 9 10-25 xxxxxx 26-40L <br /> an-Made conduits which increase vertical migration <br /> f Leachate (i.e., septic systems, water wells, ponds) <br /> None Unknown resent <br /> - <br /> nique site features: Recharge area, coarse soil, nearby wells. <br /> At least ore than <br /> xxxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS I 0 _ <br /> 'ample Result: (B/,T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 Pts 40 pts or less <br /> MAXIMUM ALLOWABLE B•T-X-E LEVELS (PPM) 1 SO 50 50 .3 ,3 % E <br /> 1. 1. NAS <br /> ample Result: <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) ASOLINE 1000 100 10 <br /> TPH <br /> IESEL 10,000 1000 100 <br /> OOTNOTES: ***If documented soil and/or <br /> ground water contamination is present, do not camptete 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 /> ,22 If Precipitation is > 40 inches, score 0 points. <br /> L Levels for BTXBE are not applicable at a TPH concentration of 10 PPM (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BT% 8 E or TPN Concentrations > Allowable Levels Yes0 <br /> /\ <br /> 2. Recommend Site Closure es oIf Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED i <br /> BY A SUPERVISOR/SENIOR <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 />