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SAN JCA0' COUNTY PUBLIC HEALTH SERVICES/ENVIRONMEVT; CALTH DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATL. DATE( <br /> NAME Of FACILITY S (SWEEPS CODE( <br /> ADDRESSI / r ti, ��� Sic TANK 10 xl - <br /> TANK SIZE FUEL TYPE �J, <br /> 11. GENERAL SITE HISTORY r <br /> IIs permit current?IYesI No Permit U - (Facility Status Codel IOac.Soil/GW Cant Yes INo <br /> N number of Tanks at facility Age of Tanks(if available) Type of Tank Steell Ifbrgll ISngl Duallq <br /> III. TANK HISTORY <br /> Was Tank tested?IYes I No Failed precision test ? Yes INoI IIf yes, give date(&)( <br /> [Was a repair made to the tank system? YesI No IIf yes, what was repaired? <br /> was repair done under inspection?(YesI INo Were soil samples analyzed?(Yes INoI BTXEI ITPH-GI ITPH-O IPb/EDB( <br /> Type of maiLure/discharge catastrophic long-carpe leakage) overfill )unknown) ocher: <br /> !V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No IDepth to Ground Water) IRef/Year Average Annual Precipitation A= 14 10-25 <br /> On-Site WeLL(s)IYes No INumber & Type IrrI (Dan Pub <br /> S Scare 5 Score S Score <br /> Distance to Welt(s) from Tank ft; ft; ft C 10 pu C 9 Pis C 5 pts <br /> 0 if 0 if 0 if <br /> R condition R condition .R condition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> (Minimae Depth to groundwater from the Soil Sample (feet) C I >100 I I51-100 25-50\1 <br /> (Fractures in subsurface (applies to foothills or mountain areas) I None I Unknown I (Present <br /> Average Annual Precipitation (inches) xxxx <10 9 110-25 jxxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of Leachate Ci.e., septic systems, water wells, ponds) I None I Unknown I Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. I Ai least) IMorc than <br /> =x'= None anal one <br /> COLUMN TOTALS>>>TOTAL POINTS « « <br /> Sample Result: (S T X OR E) RANGE OF TOTAL POINTS 49 pts or more I 41 - 48 pts I 40 pts or Less <br /> � L O I - D � <br /> Y(3E 0, .3�{ om5� MAXIMUM ALLOWABLE 3-T-X-E LEVELS (PPM) 11 50 50� 50 .3 3 1.1 1. NAA3 <br /> Sample Result: GASOLINE 1000 100 I 10 <br /> MAXIMUM ALLOWABLE TPN LEVELS (PPM) <br /> TPH DIESEL 10,000 I 10OD I 100 <br /> FOOTNOTES: —If docuoented soil and/or ground water canxamineifon is present, do not conolete the Leaching potential <br /> analysis. (i.e., site is currently an UGT Contamination List for soil or ground water.) <br /> \1 If depth is > 5 ft. aro < 25 ft., score 0 points- If depth <=5 ft., do rot use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or T00 ,opn (diesel). <br /> '/I. STAFF RECOMMENDATION/CONCLUSION rna4l&-('— eJp��" <br /> 1. Are BTX & E or TPH Concentrations > ALlawable Levels -YesI No fAiv ( v '1.�PA" /O M1?,$� KY' <br /> d� <br /> 2. Recommend Site Closure YesI No If Ties, Refer to Site Mitigation for Evaluation <br /> V11. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES( NOI (REFERRED TO SITE MITIGATION FOR EVALUATIGNIYESi INOI <br /> DATE REFERRED / / IDATE CLOSORE LETTER NAILED <br /> NAME OF <br /> EVALUATOR <br /> E4 23 80 (UGTWKSHT)\5/90 <br />