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SAN JOAOIIt,JUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTALTH DIVISION z <br /> 1. UGST WORK/SHEET FOR SITE CLOSURE EVALUATION Y ATE <br /> C ' <br /> AME OF FACILITY 0 ucle1h�f WEEPS CODE <br /> DRESS Li 9 _ Ltit (5�na" a, [TANK ID If <br /> ANK SIZE cp ';ISu' UEL TYPE D(Stj <br /> 11. GENERAL SITE HISTORY 300 r^S <br /> Is permit currentT es o ermit M - acility Status Code oc.Soi l/GW Cant as o <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tank IS <br /> Leel I Fbrgl I 13n9t Dual <br /> 111. TANK HISTORY <br /> Jas Tank tested7 ec 1001 ailed precision test 7 es iI. If yes, give date(s) <br /> as a repair made to the tank system? as No f yes, what was repaired7 <br /> Jas repair done order inspection? es o ere soil snipes analyzed? es o TXE PH-G PH-D b/EDB <br /> Type of failure/discharge atastrophic long-term leakage vert ill nown ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received as I L40 epth to Ground Water 11of/Year 'd ; b� verage Annual Precipitation = 4 110-25 <br /> )n-Site Wells) es I o I umber 8 Type Irr om ub <br /> S Score S Score S Score <br /> istance to Wells) from Tank ft; ft; ft C 10. pts C 9 pts C i pts <br /> 0 if 0 if 0 if <br /> R ondition 0. condition R ondition <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) -100 1-100 Q 25-50X2 <br /> Fractures in subsurface (applies to foothills or mountain areas) U None Unknown resent <br /> verage Annual Precipitation (inches) xxxx <10 9 10.25 xxxxxx 26-40X2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water welts, ponds) None Unknown resent <br /> pique site features: Recharge area, coarse soil, nearby wells. q At least ore than <br /> x Nine 1 onepp�� one <br /> COLUMN TOTALS»>TOTAL POINTS + 18 ♦ V - J <br /> ampleResyIt• (� B T�( R E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> 1500 <br /> CA I }. 8 T % E <br /> 1 / MAXIMUM ALLOWABLE B-7-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA,L3 <br /> aammpple R t• f �'l0 — <br /> iyoo + IktAc.11, 3PP IMUM ALLOWABLE TPH LEVELS (PPM) ASOLINE 1000 100 10 <br /> NUQ I IpM TPH 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 /> 11 If depth is > 5 ft- and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> X2 If precipitation is > 40 Inches, score 0 points. <br /> •X23 Levels for BTXBE are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION C _ <br /> 1. Are BTX d E or TPN Concentrations > Allowable LevelsYes v o I <br /> I2. Recommend Site Closure lyes I�o If Yes, Refer to Site Mitigation for Evaluation 1 l <br /> V11. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIORfie <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUAT ES 0 I r <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UG7WKSHT)\5/90 r <br />