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SAN JOAOUIa—_OUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H­._TH DIVISION <br /> 1• UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE / �s <br /> AME OF FACILITY I r / WEEPS CODE <br /> DRESS i � Te- ANK ID # <br /> TANK SIZE IFUEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> z: <br /> Is permit current7 es Il. ermit # - aciLity Status Code oc.Soi L/GW Cont es o <br /> umber of Tanks at facility ge of Ianks(if available) ype of Tank teal Fbrgl ngl Dual <br /> III. TANK HISTORY <br /> as Tank tested? as IF <br /> ailed precision test ? as o If yes, give date(s) <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> as repair done under inspecti on7esF 40 ere soil samples analyzed? es o TXE PH-G PH-D b/EDB <br /> ng-term <br /> ype of failure/discharge atastrophic loLeakage vert ill nknown cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received as o epth to Ground Water C� of/Year ; DL verage Annual Precipitation = 4 11 <br /> 0-25 <br /> n-Site Wells) eso umber 8 Type Irr om ub <br /> S Score S Score S Score <br /> istance to Wett(s) 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 ondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) I - S a 3 S >100 1-100 25-50L <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> Average Annual Precipitation (inches) xxxx <10 9 10-25 KxxXMx 26-4012 <br /> Ian-Made conduits which increase vertical migration <br /> t Leachate (i.e., septic systems, water wells, ponds) None Unknown Present <br /> pique site features: Recharge area, coarse soil, nearby watts. At least lore than <br /> xxxx Nine we one <br /> COLUMN TOTALS»>TOTAL POINTS � 3 " <br /> ample Result. (3 T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> 11T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 SO .3 .3 1. 1. W_3 <br /> Sample j� Resulyt: SOLINE 1000 100 10 <br /> fJU 0 AXIM)M ALLOWABLE TPH LEVELS (PPM) <br /> v f 0 TPH //j ��� �yy._� IESEL 10,000 1000 100 <br /> FOOTNOTES: "`If documented soil and/or ground water contamination is present, do not complete the leaching potential <br /> analysis. (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 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 n/ <br /> I2. Recommend Site Closure lyes I o I If Yes, Refer to Site Mitigation for Evaluation <br /> VII. 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 /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR So Ai <br /> EH 23 80 (UGTWKSHT)\5/90 <br />