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SAN JOAOUISOOEOUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL DIVISION DATE <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> 1. SWEEPS CODE <br /> NAME OF FACILITY 1 {/����"� TANK ID 9 <br /> ADDRESS ` �^ <br /> TANK SIZE FUEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> • Facility Status Cade Doc.Soil/GW Cont Yes No <br /> is permit current? Yes No Permit R - <br /> Number of Tanks at facility <br /> Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual <br /> Ill. TANK HISTORY <br /> Was Tank tested? Yes No <br /> Failed precision test 7 Yes No if yes, give dates) <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? <br /> Was repair done under inspection? Yes No Were soil samples anoLyzed? Yes No BTXE TPH-G TPH-D Pb/ED3 <br /> Type of failure/discharge I catastrophic long-term leakage overfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> ples Received Yes No Depth to Grpurd Water Ref/Year <br /> Average Annual Precipitation A=114 10-25 <br /> Soil Sam <br /> No Number & Type !rr Dom Pub S Score S Score <br /> On-Site Well(s) Yes S Score <br /> ft; ft; ft C 10 pts C i pis CO if <br /> Distance to WeLI(s) from Tank O if 0 if <br /> R condition R condition R condition <br /> E ;s mei E is met E is met <br /> V. Site Feature - Leaching Potential Analysis is met is <br /> 1 <br /> >100 <br /> N ininxm Depth to groundwater from the Soil Sample (feet) 19 Unknown Present <br /> aNone <br /> Fractures in subsurface (applies to foothills or mountain areas) 4 <10 9 10-25 xxxxxxx 26-40\2 <br /> xxxxxx <br /> Average Annual Precipitation (inches) <br /> Man-Made conduits Which increase vertical migration None Unknown Present <br /> of leachate (i.e., septic systems, water wells, ponds) At least) More than <br /> Unique site features: Recharge area, coarse soil, nearby wells. XxXxxx one one None U <br /> COLUMN TOTALS» TOTAL POINTS <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> B T X E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA 10 <br /> GASOLINE 1000 <br /> 100 10 <br /> Sample Result: 1000 100 <br /> MAXIMUM ALLOWABLE TPN LEVELS (PPM) DIESEL 10,000 <br /> TPH <br /> ----i <br /> ***If documented soil and/or ground water contamination is present, do not complete the leaching potential <br /> FOOTNOTES: <br /> analysis. (i.e., site is currently P� UGT points. <br /> ifdepthContamination fest do <br /> rnot1 usertable. Wafer. <br /> \1 If depth is > 5 ft. and 25 ft. score 0 tots. [f depth <br /> \2 if precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BT% & E or TPH Concentratio Allowable Levels *Yes No <br /> 2. Reeortmend Site Closure Yes No *If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE CLOSURE LETTER MAILED / / <br /> DATE REFERRED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />