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SAN JOAGlJ11F`r)NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HETt[PH DIVISION q <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE y. P;2— l Z <br /> NAME OF FACILITY �v�tc 5 Pmimat � ) EEPS CODE 1 �325 <br /> DDRESS 3`f N �� (_4.v..2 �p�, l ANK ID <br /> TANK SIZE /jp h UEL TYPE Zt-5 <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? es o ermit # acility Status Code 5t ,,.Soil/Gw Cont es o <br /> umber of Tanks at facility ' ge of Tanks(if available) Jr%�_ ype of Tank teel rgl ngl -Vaa I <br /> III. TANK HISTORY <br /> as Tank tested? es o ailed precision test ? es o If yes, give dates) <br /> as a repair made to the tank system? as No f yes, what was repaired? <br /> Ons repair done under inspection? es o ere soil samples analyzed? es TXE -G -D b/EDB <br /> Type of failure/discharge atastroph is Long-term leakage verfill newn Cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> -oil Samples Received as epth to Ground Water S5 of/Year lg ffi verage Annual Precipitation = 4 10-25 <br /> n•Site Well(s) IT <br /> as I INo usher 8 Type Irr om I ub <br /> S core s core S Score <br /> istance to Wells) from Tank ft; ft; ft - C 10 pts C pts C 5 pts <br /> 0 if 0 if 0 if <br /> R aldition R ondition 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)AE,.(or. Z >100 1-100 CJ 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) p None Unknown resent <br /> verage Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 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 soil, nearby wells. �i At least ore than <br /> xxxxx None vl one one <br /> COLUMN TOTALS>>>TOTAL POINTS Z D + Ig * `7 Z_ <br /> ample Result: (6 T % OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> X ND 1.0 <br /> rpm B T X E 6 T X E <br /> MAXIMUM ALLOWABLE B-T•X-E LEVELS (PPM) 1 50 50 SO .3 .3 1. 1. NA\3 <br /> ample Result;F ASOLINE 1000 100 10 <br /> F <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> Is TPH M IESEL 1 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 UST 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 ,p`pm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION ND t: 015h <br /> 1. Are BTX 8 E or TPN Concentrations > Allowable Level sYes o Wt C}5 -RBT <br /> I2. Recommend Site Closure 1YesI INO I IIf Yes, Refer to Site Mitigatial for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> .ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES I IND 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 />