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SAN JOAOUI` JNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H H DIVISION <br /> ^ <br /> [, UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE t' <br /> NAME OF FACILITY u S �� SWEEPS CODE j <br /> ADDRESS 3/3 nn TANK lD # <br /> TANK SIZE r Q� FUEL TYPE U),4StZ, C.. <br /> 11. GENERAL SITE HISTORY <br /> e.r <br /> is permit current? Yes No Permit # - Facility Status Code Doc.Soil/GW Cont Yes No <br /> Number of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Oual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test ? Yes No if yes, give date(s) <br /> Was a repair made to the tank system? Yes Hol if yes, what was repaired? ChdCOL lrev"4.2— <br /> was repair done under inspection? Yes No Were soil saples analyzed? Yes Na BTXE "" T__PHH�-��GI TPH-0 Pb__/EDB <br /> Type of failure/discharge catastrophic long-term Leakage overfill unknown other:-riv/ur.., it-clljp <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Sail Samples Received Yes No Depth to Ground Water y0 Ref/YearV(a Average Annual Precipitation A-114 10-25 <br /> On-Site Welt(s) Yes No Nurber & Type Irr Da Pub <br /> S Score 5 Score 5 Score <br /> Distance to WeLL(s) from Tank it; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R conditfon R condition R condition <br /> V. Site Feature - Leaching Potential Analysis 'e is met E is met E is met <br /> Minimum Depth to groundwater from the Soil Sample Cfeet) 50 >100 51-100 1 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) 0 None Unknown I Present <br /> Average Annual Precipitation (inches) xxxxxxl <10 9 10-25 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wet Ls, cords) None Unknown I Present <br /> Unique site features: Recharge area, coarse soiL, nearby welts. At least More than <br /> xx]1oU[x e Non / one j�ane <br /> COLUMN TOTALS»>TOTAL POINTS 0 / • _ / <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> B T % I E8 i X E <br /> MAXIMUM ALLOWABLE S-T-X-E LEVELS (PPM) 1 50 50 5 .3 .3 1. 1. NA1 <br /> 3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPN LEVELS (PPM) <br /> TPH DIESEL 10,000 1000 100 <br /> FOOTNOTES: —If documented soil anun <br /> arid/or ground water contamination is present, do complete the Leaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or grand 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 BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION ijc_r VAI-lb n NSD,�IK OOF"VC SOIL_ <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels -Yes No17 <br /> 2. Recommend Site Closure Yes No +If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION TES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER NAILED / / <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />