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SAN JOAV COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAAALTH DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY WEEPS CODE <br /> DRESS 2d ANK ID <br /> v <br /> TANK SIZE UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> vy <br /> Is permit current? es o ermit IF <br /> acility Status Code 5 oc.Soi l/GW Cwt es o <br /> umber of Tanks at facility 3 ge of Tanks(if available) ype of Tank teel kjFbrgl ngl Dual <br /> 111. TANK HISTORY <br /> Jas Tank tested? es 140 ailed precision test 7 es o If yes, give date(s) <br /> Jas a repair made to the tank system? es No f yes, what was repaired? <br /> as repair done under inspection? es o ere soil samples analyzed? es o TXE I PH-G I PH-D b/EDB <br /> Type of failure/discharge atastrophic long-term leakage verfill noun ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received as o epth to Ground Water of/Year verage Annual Precipitation k= 4 0.25 <br /> -Site Well(S) as o umber 8 Type Irr oo ub <br /> 5 Score S I Score S 3core <br /> istance to Wells) from Tank ft; ft; ft C 10 Pts C 9 Pts Ci Pts <br /> 0 if 0 if 0 if <br /> R ondition R condition R ondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimxm Depth to groundwater from the Soil Sample (feet) >100 1-100 25-5011 <br /> Fractures in subsurface (applies to foothills or mountain areas) v None Unknown resent <br /> verage Annual Precipitation (inches) xxxxxx <10 9 10-25 KXXXXXX 26.40E <br /> Ian-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None 9 Unknown resent, <br /> nique site features: Recharge area, coarse soil, nearby wells. At leas[ 4ore than <br /> xxxx None 9 we one <br /> COLUMN TOTALS>>>TOTAL POINTS 10 + Z + ,moi Z <br /> Sample Result: (8 T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts '- 40 pts or less <br /> 3 6 B T % E 8 T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA,L3 <br /> ample Result: ASOLINE 1000 100 10 <br /> A%IMUM ALLOWABLE TPH LEVELS (PPM) <br /> 'q ZD4LL TPH IESEL 10,000 1000 100 <br /> OOTNOTES: ...if documented soil and/or ground water cont mi notion is present, do not complete the leaching potential <br /> analysis. (i.e., site is currently on LOT 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 /> ,L2 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 BTX 8 E or TPH Concentrations > Allowable Levels Yes 'X4 o <br /> I2. Recommend Site Closure Yes I �o FIf 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 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 />