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SAN JOAOUI,_.OUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> UATION ATE 2 z L <br /> I. UGST WORKSHEET FOR SITE CLOSURE EVAL <br /> AME OF fACi LITY EEPS CODE <br /> [TANK ID # <br /> ANK SIZE a_��� UEL TYPE <br /> 11. GENERAL SITE HIST .* <br /> .s permit current? as o ermit # acility Status Code oc.Soi l/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) IT <br /> ype of Tank teel Fbrgl ngl Dual <br /> III. TANK HISTORY <br /> as Tank tested7 es o ailed precision test ? es o If yes, give date(s) <br /> as a repair made to the tank system? as No f yes, what was repaired? <br /> ns repair done under inspection? es o ere soil samples or ITTXE T ITPH-G I PH-D b/EDB <br /> Type of failure/discharge atastrophic Long-term leakage verfill nknown 1 10ther: <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 Waters of/Year f� verage Annual Precipitation = 4 10-25 <br /> -Site Wells) IT <br /> as o 1 liumber 8 Type Irr om ub <br /> S Score S Score S Score <br /> istance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R condition R condition R condi tion <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Semple (feet) >100 1-100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None C( Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 ,xxxxx 26-40\2 <br /> an-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. G At least lore than <br /> xxxxx None ( one one <br /> COLUMN TOTALS»>TOTAL POINTS * <br /> ample Result: (B T % OR E) RANGE OF TOTAL POINTS 9 pts or more 1 - 48 pts 40 pts or less <br /> 13Tx ND .a� <br /> B T X E 0 T X E <br /> PP <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 .3 .3 1. 1. NA\3 <br /> -ample,Resu�IT �-iA AXIMUM ALLOWABLE TPH LEVELS (PPM) ASOLINE 1000 100 10 <br /> Ser TPN IESEL 10,000 1000 100 <br /> OOTNOTES: ***If documented soil and/or ground water contamination is present, do- ompl eta the leaching 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 BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1, Are BTX 8 E or TPH Concentrations Allowable Levels Yes o <br /> 2. Recommend Site Closure as o if Yes, Refer to Site Mitigation for Evaluation <br /> Vil. REVIEW EVALUATION - TO BE C014PLETED BY A SUPERVISOR/SENIOR <br /> ,ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> )ATE REFERRED / / ATE CLOSURE LETTER MAILED / / <br /> AME OF <br /> .VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />