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SAN JOAOU`W-COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL RCILTH DIVISION /� <br /> I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE 0 <br /> AME OF FACILITY WEEPS CODE <br /> DRESS, .e ANK ID p 53 L <br /> TANK SIZE V�U UEL TYPE <br /> 11. GENERAL SITE HISTORY / <br /> Is permit current? as o I I," ermit p IFacility Status Code /Ycr oc.Soi L/GW Cont 1Yes o <br /> urber of Tanks at facility lkge of Tanks(if evailabLe) Type of Tank Leel Fbrgl tgl Dual <br /> Ill. TANK HISTORY <br /> as Tank tested? as iJ <br /> o � Jailed precision test 1 If es o If yes, give date(s) <br /> as a repair made to the tank system? 1Yes No 1 11f yes, what was repaired? <br /> as repair done under inspection? as o ere soil samples analyzed? es o TXE PH-G PH-D b/EDB <br /> Type of failure/discharge atastrophic long-term Leakage verfitt nknown Cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oiL Samples Received es 0 epth to Ground Water G/ It <br /> of/Year ,4 ; verage Annual Precipitation N= 11 <br /> 4 11 <br /> 0-25 <br /> -Site Well(s) es o umber 8 Type Irr cm I ub <br /> S core S Score S 3core <br /> istance to Welt(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if O if 0 if <br /> R condition R conditim R ondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) � >100 1-100 25-5QL1 5°Y� <br /> Fractures in subsurface (applies to foothills or mountain areas) L: None Unknown resent <br /> Average Annual Precipitation (inches) Kxxxxx 00 9 10-25 xxxxxx I 26-40L <br /> Ian-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None C Unknown resent <br /> pique site features: Recharge area, coarse soil, nearby wells. At least ore than <br /> xxxxx None ane one <br /> COLUMN TOTALS>>>TOTAL POINTS L' + 7 + <br /> angle ResulOR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> y''qu'�'t', ✓7L <br /> B T % E B T I% I E <br /> MAXIMLW ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NAL <br /> ample Result: ASOLINE 1000 100 10 <br /> J;l AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> L TPH IESEL 10,000 1000 100 <br /> FOOTNOTES: ..*If documented soil and/or ground water contamination is present, do not caiptete the Leaching potential <br /> analysis. (i.e., site is currently on UGT Contanination List for soil or ground water.) <br /> .1 If depth is > 5 ft. and c 25 ft., score 0 points. If depth c=5 ft., do not use table. <br /> L 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 /> V1. STAFF RECOMMENDATION/CONCLUSION LVIS e( +t-v K 0,L"l±C b(d S " 0ct4-E� /,),I Std'Y4 <br /> / <br /> cYIQ <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recoamend Site Closure 1Y <br /> es o If Yes, Refer to Site Mitigation for Evaluation <br /> V11. 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 / 3 / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR r4= <br /> EH 23 80 (UGTWKSHT)\5/1 <br />