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SAN JOAOUIyi..,OUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL '.-�TH DIVISION <br /> I• UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY WEEPS CODE <br /> ANK IO s <br /> TANK SIZE IFUEL TYPE <br /> II. GENERAL SITE HISTORY <br /> Is permit current? es 0 ermit N acility Status Code oe.Soit/GW Cont es o <br /> umber of Tanks at facility Be of Tanks(if available) IType of Tank 1,teal I lFbrgi ngl I Dual <br /> III. TANK HISTORY <br /> Jas Tank tested? es IFailed precision test ? as o If yes, give dates) <br /> Jas a repair made to the tank system? as No f yes, what was repaired? <br /> Jas repair done under inspection? as o ere soil samples analyzed? es Jo TXE PH-G PH-D b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfill I knknown I i0ther: <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 Water ZS of/Year -'> -/ verage Annual Precipitation 4 0.25 <br /> -Site Wells) IYes I o I umber 8 Type Irr om I 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 onditi on R condition R ondition <br /> Site Feature . Leaching Potential Analysis 3 - )-S—= //, E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1.100 Q 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) D None I Unknown resent <br /> verage Annual Precipitation (inches) xxxxxx <10 9 10-25 Kxxxxxx 26.40\2 <br /> an-Made conduits which increase Vertical migration ,1 <br /> f leachate (i.e., septic systems, water wells, ponds) w None Unknown resent <br /> Inique site features: Recharge area, coarse soil, nearby wells. At least lore than <br /> pXXxx None 9 one J(lone <br /> COLUMN TOTALS»>TOTAL POINTS '/�0 . + a J G <br /> 'ample Result: (D T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> X 6T X E B T % E <br /> /- MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: ASOLTNE 1000 100 10 <br /> A%IMUM ALLOWABLE TPN LEVELS (PPM) <br /> 700 �.- 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 /> 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 BT%8E are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION r, <br /> 1, Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation P�- <br /> VII. REVIEW EVALUATION - TO BE CCMPLETED BY A SUPERVISOR/SENIOR <br /> .ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES EFERRED TO SITE MITIGATION FOR EVALUATION ES O <br /> ATE REFERRED ATE CLOSURE LETTER MAILED <br /> AME OF <br /> .VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />