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SAN JOAOUtA40UNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL a LTH DIVISION <br /> 1• UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE ,( �� <br /> AME OF FACILITY WEEPS CODE <br /> QO a Cc' <br /> ODRESS / ,yJoe-z / ANK ID k <br /> ANK SIZE dDQ UEL TYPE u �'`' <br /> 11. GENERAL SITE HISTORY <br /> r* <br /> Is permit current? es o ermit 8 acility Status Code oc.Soft/GW Cont es o <br /> Enter of Tanks at facility ge of Tanks(if available) ype of Tank test brgl 1 6not 1 Dual <br /> 111. TANK HISTORY <br /> Jas Tank tested? es o sited 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 qo ere soil samples analyzed? es 1 )o 1 TXE PH-G PH-D b/EDB <br /> ypo of failure/discharge stastrophfc long-term leakage verfftl known1 10 ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es 1401 epth to Ground Water 1/ of/Year verage Annual Precipitation 4 10-25 <br /> )n-Site Welt(s) es I o umber 8 Type Irr om ub <br /> S score S Score S core <br /> istance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C pts <br /> '0 if 0 if 0 'f <br /> R onditi on R condit fon R endf t on <br /> Site feature - Leaching Potential Analysis E is met E is met E 's met <br /> inimum Depth to groundwater from the Soft Sample (feet) >100 1.100 ,5 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) `a None Unknown Iresent <br /> verage Annual Precipitation (inches) xxxxx 00 9 10-25 xxxxxx 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 /> Inique site features: Recharge area, coarse soft, nearby wells. At least 1Ore than <br /> xxxx None one one <br /> COLUMN TOTALS>»TOTAL POINTS + + <br /> ample Result: (S T X OR E RANGE OF TOTAL POINTS 9 pts or more 41 48 is 40 pts or less <br /> MAXIMUM ALLOWABLE B-T•X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. Nq\3 <br /> ample Result: ASOLINE 1000 iO <br /> FAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPN IESEL 10,000 1000 100 <br /> oOTNOTES: ***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 soft 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 BTXSE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX S E or TPH Concentrations Allowable Levels Yes —tol tlk <br /> 2. Recommend Site Closure IYes o If Yes, Refer to Site Mitigation for Evaluation <br /> V11. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SE <br /> .ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES I 0 I EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE RErJIMB GZ, / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> -VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/9 <br /> EH 29 80 <br />