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SAN JOAOUTA..Q)NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL I CH DIVISION <br /> 1• UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> OAME OF FACILITY C' ( WEEPS CODE ' C/ <br /> ODRESS -7 I L)N- ANK ID # <br /> TANK SIZE 5/j� UEL TYPE _ <br /> It. GENERAL SITE HISTORY <br /> t� <br /> Is permit current? es o ermit # I IFacility Status Code oc.Soi(/GW Cont es o <br /> umber of Tanks at facility Be of Tanks(if available) ype of Tank teel Fbrgl ngl Dual <br /> 111. TANK HISTORY <br /> as Tank tested? es I IN01 ailed precision test ? es I ilo If yes, give date(s) <br /> as a repair made to the tank system? IYes No 1 11f yes, what was repaired? <br /> ns repair time under inspection? es o ere soil samples analyzed? es I to I f1TXE PH-G PH-D b/EDB <br /> Type of failure/discharge atastrophic long-term leakage verfill nknown ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> .oil Samples Received as o epth to Ground Water of/Year verage Annual Precipitation = 4 10-25 <br /> )n-Site Wells) es I o umber & Type Irr cm ub <br /> S Scars S Score Score <br /> istance to Well(s) from Tank it; ft; ft C 0 pts C pts C pts <br /> 0 if 0 if 0 if <br /> R onditi on R condition 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 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> vcrsge Annual Precipitation (inches) KXXXXX <10 9 10-25 AXXAXXX 26-40\2 <br /> nn-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None -- Unknown resent <br /> lnique site features: Recharge area, coarse soil, nearby wells. At least lore than <br /> xxxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS l D Mm�vlt, <br /> ample Result: (B T X,OR E) RANGE OF TOTAL POINTS 9 pts or more40 pts or less <br /> B T X EL— .Y7-� MAXIMUM ALLOWABLE B-T-X•E LEVELS (PPM) 1 50 50 50 NA\3 <br /> 'a le Resullt,/•' � nnI�\�J ASOLINE 100010 <br /> r &�Iv' 1a" AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPN IESEL 10,000100 <br /> OOTNOTES: •"•If documented soil and/or ground water contamination is present, daching 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 /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTX&E are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> r1. Are BTX & E or TPH Concentrations > Allowable Levels Yes I iNo <br /> I2. Recommend Site Closure as o If Yes, Refer to Site Mitigatial for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> .ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERREO TO SITE MITIGATION FOR EVALUATION ES [101 1 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF /// <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />