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SAN JOAOUINtEIMNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H, H DIVISION <br /> I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY WEEPS CODE <br /> DDRESS � ` � ANK ID # <br /> TANK SIZE 50 L`ad IF UEL TYPE <br /> II. GENERAL SITE HIST&Y <br /> V M* <br /> Is permit current? es o Permit # acil i[y Status Code oc.Soil/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tank Iiteel I IFbrgl I ISngl I Dual <br /> III. TANK HISTORY <br /> as Tank tested? es o ailed precision test ? es o If yes, give date(s) <br /> as a repair made to the tank system? Yes No f yes, what was repaired7 <br /> ns repair done under inspection7 es o =ere samples analyzed? es to TXE PN-G PN-D b/EDD <br /> Type of failure/discharge atastrophic long-term Leakage I verf ill nknown then. <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received ITes o 1 epth to Ground Water 0' kf/Year verage Annual Precipitation = 4 10-25 <br /> -Site Wells) es o umber 8 Type Irr om I ub <br /> S Score 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 condition 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) >100 cl1.100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 xxxxxx 26.40\2 <br /> an-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> Ii a site features: Recharge area, coarse soil, nearby wells. ) At Least lore than <br /> xxxxx None 1 one one <br /> COLUMN TOTALS»>TOTAL POINTS a <br /> ample Result: (0 T X OR E) RANGE OF TOTAL POINTS 9 48 pts 40 pts or less <br /> T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 13 1. 1. NA\3 <br /> -ample Result: �� ASOLINE 100 10 <br /> Yi AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPN 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 BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 Pon (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o <br /> F 7z <br /> 2. Recommend Site Closure es Vo 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 I 0 EFERRED TO SITE MITIGATION FOR EVALUATIONES JO <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> .VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />