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SAN JOAOUTANTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL PH DIVISION q <br /> 1• UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE `�, C-j I <br /> AME OF FACILITYWEEPS CODE <br /> DRESS � C)J(D q ANK ID # - <br /> TANK SIZE Q UEL TYPE <br /> II. GENERAL SITE HISTORY <br /> 41t <br /> Is permit current? es o ermit # acility Status Code oc.SoiL/GW Cont es o <br /> IF I <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tank Leel Fbrgl I IS <br /> rggl Dual <br /> 111. TANK HISTORY <br /> as Tank testedt es IF <br /> ailed precision test 7 as o If yes, give dates) <br /> as a repair made to the tank system? Yes No f yes, what was repaired? <br /> Jas repair done under inspection? es o ere soil samples analyzed? es o TXE PH-G PH-D b/EDB <br /> Type of failure/discharge atastrophic long-term leakage I verfill nknown I lather: <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 .5 of/Year RX verage Annual Precipitation 4= 11 <br /> 4 11 <br /> 0-25 <br /> )n-Site Well(s) es o umber 8 Type Irr om I ub <br /> S Score S Score S Score <br /> istance to WeLI(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> V. <br /> R ondition R ondition R ondition <br /> Site Feature - Leaching Potential Analysis 3 s��o =a 5 E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 .5 25-50 1 <br /> Fractures in subsurface (applies to foothills or mountain areas) , None Unknown resent <br /> verage Annual Precipitation (inches) KXXMX <10 9 10-25 KMxmx 26-40L <br /> Ian-Made conduits which increase vertical migration Q <br /> f leachate (i.e., septic systems, water wells, ponds) None I Unknown resent <br /> pique site features: Recharge area, coarse soil, nearby wells. At least 4ore than <br /> xxxxx None one C one <br /> COLUMN TOTALS>>>TOTAL POINTS D f -S T.�-- <br /> ample Result: IS TT X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> IJ CJ a P(y` 01�_O.0 8 T X E 8 T X E <br /> /" �' MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NAL <br /> ample Res}�l t: SOLINE 1000 100 10 <br /> N D .1- PQ m AX IMUN ALLOWABLE TPH LEVELS (PPM) <br /> (((JJJ���"` 1 1 TPH-V 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 /> \1 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 /> \3 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 o L-- <br /> 2. <br /> 2. Recommend Site Closure es I L40 I If Yes, Refer to Site Mitigation for Evaluation <br /> VII. 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 f/l <br /> EH 23 80 (UGTWKSHT)\5/90 <br />