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SAN JOAO. COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAIL.LTH DIVISION <br />I• UGST WORKSHEET FOR SITE CLOSURE EVALUATION A1c �' b <br />AME OF FACILITY _ _ r� 1 F� WEEPS CODE <br />DRESS --' ' i `-7 C-- -C oj ,1f y ANK 1D # - <br />TANK SIZE UEL TYPE C- <br />11. GENERAL SITE HISTORY <br />111. TANK HISTORY <br />as Tank tested? <br />as <br />I <br />IN01 <br />ailed precision test ? <br />as <br />1IO b; <br />o <br />If <br />yes, give date(s) <br />0.25 <br />as a repair made to the tank system? as I No f yes, what was repaired? <br />es <br />Jos repair done under inspection? <br />permit current? <br />es <br />es <br />o <br />o <br />ermit # <br />- <br />acility Status Code <br />PH -G <br />Score <br />10 pts <br />if <br />ondition <br />is met <br />oc.Soi L/GW <br />Cont <br />as <br />r <br />!o <br />-ber of Tanks at facility <br />atastrophic <br />long-term leakage <br />ge of Tanks(if available) <br />verfill <br />ype of Tank <br />Leel <br />51-100 <br />Fbrgl <br />25-501 <br />nil <br />I Dual <br />111. TANK HISTORY <br />as Tank tested? <br />as <br />I <br />IN01 <br />ailed precision test ? <br />as <br />1IO b; <br />o <br />If <br />yes, give date(s) <br />0.25 <br />as a repair made to the tank system? as I No f yes, what was repaired? <br />es <br />Jos repair done under inspection? <br />es o <br />ere soil samples anal yzed7 <br />es <br />o <br />om <br />TXE <br />ub <br />PH -G <br />Score <br />10 pts <br />if <br />ondition <br />is met <br />PH -D <br />Score <br />9 pts <br />if <br />condition <br />is met <br />b/EDB <br />Score <br />5 pts <br />if <br />or)ition <br />is met <br />Type of failure/discharge <br />ft; ft; ft <br />atastrophic <br />long-term leakage <br />inimum Depth to groundwater from the Soil Sample (feet) <br />verfill <br />>100 <br />nknown <br />51-100 <br />they: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />Soil Samples Received <br />es <br />FOR CLOSURE <br />o <br />epth to Ground Water 6s <br />of/Year <br />1IO b; <br />verage Annual Precipitation <br />= <br />4 <br />0.25 <br />Din -Site Welt(s) <br />es <br />o <br />umber 8 Type <br />Irr <br />om <br />VALUATOR <br />ub <br />S <br />C <br />0 <br />R <br />E <br />Score <br />10 pts <br />if <br />ondition <br />is met <br />S <br />C <br />0 <br />R <br />E <br />Score <br />9 pts <br />if <br />condition <br />is met <br />S <br />C <br />0 <br />R <br />E <br />Score <br />5 pts <br />if <br />or)ition <br />is met <br />istance to WeLL(s) from Tank <br />ft; ft; ft <br />V. Site Feature - Leaching Potential Analysis (p s- II = 5 <br />inimum Depth to groundwater from the Soil Sample (feet) <br />>100 <br />9 <br />51-100 <br />25-501 <br />Fractures in subsurface (applies to foothills or mountain areas) <br />JC_ <br />None <br />Unknown <br />resent <br />%verage Annual Precipitation (inches) <br />xxxx <br /><10 <br />9 <br />10-25 <br />xxxxxx <br />26-40L <br />an -Made conduits which increase vertical migration <br />f leachate (i.e., septic systems, water wells, ponds) <br />None <br />Unknown <br />, <br />resent <br />nique site features: Recharge area, coarse soil, nearby wells. <br />xxxx <br />None <br />At least <br />one <br />4ore than <br />one <br />COLUMN TOTALS»>TOTAL POINTS <br />f <br />+ <br />.i� <br />+ <br />C <br />Sample Result: (B T X OR E) <br />til) r�I m <br />RANGE OF TOTAL POINTS <br />9 pts <br />or more <br />41 - <br />48 pts <br />40 pts or less <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) <br />B <br />1 <br />T <br />50 <br />X <br />50 <br />E <br />50 <br />B <br />.3 <br />T <br />.3 <br />X <br />1. <br />E <br />1. <br />NA_�3 <br />ample Res It: <br />N (7 4,_T 1 /yt <br />I TPN <br />ASOLINE <br />IMUM ALLOWABLE TPH LEVELS (PPM) <br />1,IESEL <br />1000 <br />100 <br />10 <br />1 <br />10,000 <br />1000 <br />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 />\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 />V1. STAFF RECOMMENDATION/CONCLUSION <br />1. Are BTX 8 E or TPH Concentrations 1> A—llowable Levels Yes o X <br />2. Recommend Site Closure es?( No I if Yes, Refer to Site Mitigation for Evaluation <br />VII- REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br />CONCUR WITH STAFF <br />RECOMMENDATION <br />FOR CLOSURE <br />ES <br />0 <br />EFERRED TO SITE <br />MITIGATION FOR EVALUATION <br />ES <br />0 <br />ATE REFERRED <br />/ / <br />ATE CLOSURE LETTER MAILEDAME <br />VALUATOR <br />_T4_ C�lil� /� <br />�- <br />EH 23 80 (UGTWKSHT)\5/90 <br />