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SAN JOAOUI "OUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL JH DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATIOL. ATE �^ _ <br /> AME Of FACILITY y WEEPS CODE <br /> DRESS I J ` n„„ _ ) �.., ANK ID # - <br /> ANK SIZE UEL TYPE �� I't�`-'�� <br /> 11. GENERAL SITE HISTORY <br /> e� <br /> s permit current? es o ermit # - acility Status Code oc.Soi l/GW Cont es o <br /> ember of Tanks at facility ge of Tanks(if available) ype of Tank teal FbrgL I 1Sng1 Dual <br /> 111. TANK HISTORY <br /> Jas Tank tested7 as IF <br /> ailed precision test 7 es o If yes, give date(s) <br /> Jas a repair made to the tank system? es No f yes, what was repaired? <br /> as repair done under inspection? es 40 ere soil samples analyzed7 as o TXE PH-G PH-D b/EDB <br /> Type of failure/discharge atastrophic long-term leakage1. verfill noun ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es o epth to Ground Water of/Year verage Arcual Precipitation k= 4 0-25 <br /> -Site Wells) Ires I o umber 8 Type Irr cm ub <br /> S core S core 5 core <br /> istance to WeLL(s) from Tank ft; ft; ft C 10 pts C pts C pts <br /> 0 if 0 if 0 f <br /> R condition R ondition R ondition <br /> W. Site Feature - Leaching Potential Analysis E is met E is met E 's met <br /> inimm Depth to groundwater from the Soil Sample (feet) >100 1-100 25.501 <br /> Fractures in subsurface (applies to foothills or mountain areas) )G None Unknown >resent <br /> verage Arcual Precipitation (inches) xxxx 00 9 10-25 xxxx 26-4012 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, polls) None Unknown resent <br /> pique site features: Recharge area, coarse soil, nearby watts. At least lore than <br /> xxxx None "I one one <br /> J 7_ <br /> COLUMN TOTALS»>T TAL POINTS (� . ,� <br /> e u (B T X OR ) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> g74' <br /> IDV/rMAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NAl <br /> Sample Result: SOLINE 1000 100 10 <br /> n t �Y� IMl1M ALLOWABLE TPH LEVELS (PPM) <br /> l-/ TPH IESEL 10,000 1000 100 <br /> FOOTNOTES: ...If documented soil and/or ground water contamination is present, do not complete the leaching potential <br /> ane lysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> 11 If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> 12 If precipitation is > 40 irches, score 0 points. <br /> ,L3 Levels for STXBE are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION D43 2.1 <br /> 1L � <br /> . Are BTX 8 E or TPM Concentrations > Allowable Levels Yes <br /> /l.�I- <br /> 2. Recommend Site Closure res I �10 771 <br /> Yes, Refer to Site Mitigation for Evaluation &Vtyl &-Ifr��Jkl <br /> VILLI. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> PTE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> EH 23 80 (UGTWKSHT)\5/90 <br />