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SAN JOAOU.. COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL m-.ALTH DIVISION 1 <br />1. UGST WORKSHEEf FOR SITE CLOSURE EVALUATION ATE I / D.� <br />AME OF FACILITY WEEPS CODE/ l <br />�y n� 0 <br />DRESS / 7� / VI (1 G J ANK ID Y <br />IANK 512E/,,I,'OC) 0 UEL TYPE <br />I1. GENERAL SITE HISTORY <br />.. <br />Is permit current? e6 o ermlC d C / 9 � a�j(i[y S[a [uS Coda � OC,SOII/GV Cor1t eti o <br />under of Tanks at facility ge of Tanks(If ave._i)lnble) u�MC Type'of Tank teal Fbrgl ngl Dual <br />111. TANK HISTORY <br />IE <br />— --- - ••. �•y,.�rvn, ruII al It uLIAIL]/LULLECF DATA Fiat IFArulur, m TrwTuw Auu ve,e. <br />-oil Samples Received <br />es <br />L <br />o <br />epth to Ground Water <br />ailed precision test 7 <br />as <br />o <br />v" If <br />you, give <br />0.25 <br />Mawde <br />to the tank eys[el7 <br />f yes, what wus repaired? <br />o <br />nder inspection?ischarge <br />Ullber Y Type <br />Irr <br />om <br />uU <br />I <br />otos trophic <br />long-term leakage <br />vert ill <br />nown <br />[her: <br />— --- - ••. �•y,.�rvn, ruII al It uLIAIL]/LULLECF DATA Fiat IFArulur, m TrwTuw Auu ve,e. <br />-oil Samples Received <br />ey <br />o <br />epth to Ground Water <br />} of/Year <br />veraUe Amual Precipitation <br />4 <br />0.25 <br />Site Well(s) <br />es <br />y' <br />o <br />I <br />Ullber Y Type <br />Irr <br />om <br />uU <br />I <br />S <br />C <br />0 <br />R <br />E <br />f <br />is uxs[ <br />0 <br />E <br />Score S <br />9 pts C <br />if 0 <br />Condition R <br />is met E <br />3core <br />i pts <br />if <br />ondition <br />is met <br />istance to Wells) from Tank <br />2—y_f t; ft; (t <br />V. Site Feature - Leaching Potential Analysis <br />iniuun Depth to groundwater from the Soil Sample (feet)FN�e <br />1-100 <br />25•SOL <br />factures in subsurface (applies to foothills or mountain ureas) <br />Unknown <br />resent <br />verage Annual Precipitation (Inches) <br />9 <br />10-25 xxxxxx <br />26.401aWMatle <br />conduits which increase vertical migration <br />f leachate (i.e., septic systems, Nater wells, ponds) <br />Unknown S <br />resent <br />ique site features: Recharge area, course soil, nearby wells. <br />xxxx <br />None <br />/5 <br />`/� <br />At least <br />one <br />4ore than <br />one <br />COLUMN TOTALS» >TOTAL POINTS <br />3& <br />+ <br />angle Result: (B T % ON E) <br />RANGE OF TOTAL POINTS <br />9 pts or more <br />41 - 48 pts 40 pts or less <br />MAXIMUM ALLOWABLE B -T -%•E LEVELS (PPM) <br />I <br />50 <br />SO <br />50 <br />.1 <br />.3 <br />1. <br />1. NAZI <br />'mmple Result: <br />TPH <br />THUM ALLOWABLE TPN LEVELS (PPM) <br />ASOLINE <br />1000 <br />1pp 10 <br />IESEL <br />10,000 <br />1000 100 <br />OOTNOTES: •••If documented soil and/or groud water contamination is present, do not complete the leaching potential <br />analysis. (i.e., site Is currently on UGT Contumina tion Lis[ for soil or ground water.) <br />jl If depth Is > 5 ft, and < 25 f[., score 0 points. If depth "5 ft., do not use table. <br />�? It precipitation is > 40 inches, score 0 points. <br />Levels for BTX&E are not applicable at a IPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br />VI. STAFf RECOWENDATION/CONCLUSION '�' -)— 1'x/1 Lam,, c6d /3 <br />1. Are BT% & E or TPN Concentrations > Allowable Levels Yes 0 <br />2. Recommend Site Closure es oIf Yes, Refer to Site Mitigation Zr Evaluation <br />VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR /SENIOR <br />ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES <br />ATE REFERRED / / ATE CLOSURE LETTER MAILED <br />ANE OF <br />-.VALUATOR <br />EII ?J DU (UGTWK5HT)%5/90 <br />