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SAN JOAOUII JNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HeRnH DIVISION <br /> 1, �UGST WORKSHEET FOR SITE CLOSURE EVALUATION AT <br /> AME OF FACILITY WEEPS CODE <br /> DRESS l -- ANK (0 it <br /> TANK SIZE (OC)C, �1_ UEL TYPE <br /> 11. GENERAL SITE HIST64Y <br /> Is permit current? es o ermit IFacility Status Code oc.Soi l/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) IType of Tank IS Leel Fbrgl ngl I Dual <br /> 111. TANK HISTORY <br /> as Tank tested? es IF <br /> ailed precision test ? as o if yes, give date(s) <br /> Jas a repair made to the tank system? as No f yes, what was repaired? <br /> as repair done under inspection? as o ere soil samples analyzed? es o T%E PX-G PH-D b/EDB <br /> Type of failure/discharge atastrophic long-term leakage verfill I 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 50 of/Year -(a verage Annual Precipitation 4= 4 0-25 <br /> -Site Wells) es I o umber 8 Type Irr om I ub <br /> S Score S Score S Score <br /> istance to Well(S) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R ondition R condition R ends ti on <br /> W. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) Sp-1)-M >100 1-100 S 25.5011, <br /> Fractures in subsurface (applies to foothills or mountain areas) l Q None Unknown resent <br /> verage Annual Precipitation (inches) Kxxxxx 00 9 10.25 xmxmx 26-401 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> pique site features: Recharge area, coarse soil, nearby wells. At least 4ore than <br /> xxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS I u + �--7 5 4 ,�- <br /> Sample Result: (B pT pX OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> NO Cc� /0 I ! 8 T X E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 SO 50 .3 .3 1. 1. NAL <br /> Sample Result: SOLINE 1000 100 10 <br /> N IMUM ALLOWABLE TPH LEVELS (PPM)I TPH IESEL 10,000 1000 100 <br /> FOOTNOTES: "•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 /> 1 If precipitation is > 40 inches, score 0 points. <br /> 1 Levels for BTXBE are not applicable at a TPN 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 <br /> I2. Recommend Site Closure Yes I l,j�fo I plf 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 ��/1 � � <br /> -VALUATOR \-�✓1.�,� - <br /> EH 23 80 (UGTWKSHT)\5/90 <br />