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SAN JOAOU�- -OUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL LTH DIVISION <br /> L UGST WORKSHEET FOR SITE CLOSURE EVALUATICNrd DATE <br /> NAME OF FACILITY P& a, �( SYEEPS CODE QCI� <br /> ADDRESS ZBC)o � "�L(C- Ro TANK ID '� 3`4 - p 93 Qz <br /> TANK SIZE t0QC)Q I FUEL IZ14 I U1 lTifS <br /> It. GENERAL SITE HISTORY <br /> Is permit current? Yes No Permit x Facility Status Cada Doc.Soil/OW Coni Yes No <br /> Nmber of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual <br /> III. TANK HISTORY <br /> was Tank tested? Yes No Failed precision test es Nc If yes, give date(s) <br /> ? Y <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? <br /> Was repair done under inspection? Yes No Were soil samples analyzed? Yesl No BTXEI TPN-GI TPH-01 Pb/EDB <br /> Type of failure/discharge catastrophic tang-termleakage I overfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Ground Water (Ref/Year Average Annual Precipitation A- 14 10-25 <br /> On-Site WeLL(s) Yes No Number & Type Irr Dam Pub <br /> S Score S Score s 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 condition 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 (feet) >100 51-100 I 125-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) More Unknown (Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxxl 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water watts, ponds) None Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> xxxxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS + . - <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 E B T X E <br /> MAXIMUM ALLOWABLE B-T-%-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. I NA\3 <br /> Sample Result; GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPN DIESEL 10,000 1000 I 100 <br /> FOOTNOTES. ' if documented soil and/or ground water contamination is present, do not complete the leeching potential <br /> analysis. (i.e., site is currently on UGT Ccntamination 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 TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 11. Are BTX & E or TPH Concentrations > Allowable Levets 'Yesl No <br /> 2. Recommend Site Closure)Yes INoI � lf 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 NOI REFERRED TO SITE MITIGATION FOR EVALUATION YES NO I <br /> DATE REFERRED / / (DATE CLOSURE LETTER MAILED <br /> i <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />