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SAN JOAOU.. COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL IrrALTH DIVISION <br />1• UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE D / — <br />AME OF FACILITY _ WEEPS CODE 111,3< <br />DRESS /--q '17S /Z%, 4'r k�.1.9,:, v. Q/' _ ANK ID p I .,? q - / / % r.--- : i <br />TANK SIZE UEL TYPE <br />11. GENERAL SITE HISTORY <br />ar, <br />Is permit current? es o ermit Y C / 3lFacitity Status Code oc.Soel/GW Cont es o <br />ismer of Tanks at facility iLWe of Tanks(if available) afro,' Type -of Tank tact Fbrgl ngl I Dual <br />Ill. TANK HISTORY <br />as Tank tested? <br />es <br />IN o <br />ailed precision test 7 <br />as <br />of/Year <br />o <br />If <br />yes, give date(c) <br />/ / / / <br />as a repair made to the tank cystaa7 esttt <br />•Site Wells) <br />s, what was repaias <br />repair done under Inspection? <br />eeType <br />uY Te <br />Irran <br />ub <br />S <br />C <br />D <br />EN <br />Score <br />10 pts <br />if <br />urdition <br />is abet <br />S <br />C <br />0 <br />R <br />E <br />Score <br />vv pts <br />if <br />condition <br />Is Inet <br />5 <br />C <br />0 <br />q <br />E <br />3core <br />- pts <br />if <br />otdition <br />is lust <br />istunce to Wells) from Tank <br />of failure/discharge <br />atustrophickage <br />inimuu Depth to groundwater trout the Soil Suaple (feet) 4r <br />vert ill <br />9 <br />f <br />nown <br />[her: <br />IV. REMOVAL HISTORY (ATTACH INSP�01011 REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />oil Salples Received <br />es <br />ogeptllypo <br />Ground Water <br />ES <br />of/Year <br />0 <br />verage Annual Precipitation <br />+ <br />4 <br />0.25 <br />•Site Wells) <br />es <br />o <br />uY Te <br />Irran <br />ub <br />S <br />C <br />D <br />EN <br />Score <br />10 pts <br />if <br />urdition <br />is abet <br />S <br />C <br />0 <br />R <br />E <br />Score <br />vv pts <br />if <br />condition <br />Is Inet <br />5 <br />C <br />0 <br />q <br />E <br />3core <br />- pts <br />if <br />otdition <br />is lust <br />istunce to Wells) from Tank <br />Z5:�ft; f[; _^_ft <br />Site Feature - Leaching Potential Aralyals <br />inimuu Depth to groundwater trout the Soil Suaple (feet) 4r <br />>100 <br />9 <br />f <br />- 1.100 <br />25-50L <br />ractures in subsurface (applies to foothitls or mountain areas) <br />Nene <br />Unknown <br />resent <br />verage Annual Precipitation (inches) <br />xxxx <br />410 <br />9 <br />10-25 <br />xxxxxx <br />26.401 <br />on -Made conduits which Increase vertical migration <br />I leachate (i.e., septic systaas, water Wells, pords) <br />None <br />Unknown <br />>resent <br />nigae site features: Recharge area, course soil, nearby wells. <br />' <br />xxxx <br />None <br />(�7 <br />/ <br />At least <br />one <br />ore than <br />COLUMN TOTALS>>>TOTAL POINTS <br />3 <br />;aapla Result: (B T X ON E) <br />RANGE of TOTAL POINTS <br />9 pts or more <br />41 - 48 pts <br />40 pts or less <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) <br />tl <br />1 <br />I T <br />50 <br />X <br />50 <br />E <br />50 <br />B <br />.3 <br />T <br />.3 <br />% <br />1. <br />E <br />1. <br />NAl <br />maple Result: <br />rl�� N rV 1 D <br />/7 TPH <br />ASOLINE <br />IMUM ALLOWANCE TPH LEVELS (PPM) <br />IE <br />1000 <br />100 <br />10 <br />SEL <br />10,000 <br />1000 <br />100 <br />FOOTNOTES: ••>If docuiented soil and/or grand water contwnination is present, do not conplete the leaching potential <br />analyses. (i.e., Sita is currently on UGT Con[aainatlon List for soil or ground water.) <br />11 If depth is > 5 ft. and c 2S ft., score 0 points. If depth A=5 ft., do nwt use table. <br />If precipitation is > 40 inches, score 0 points. <br />L Levels for BTXKE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppn (diesel). <br />VI. STAFF RECOFWENDATION/CONCLUSIONal)C W Y k " <br />1. Are DTX & E or TPH Concentrate > AtowabLe Levels Yes o �AiNWj•) 1.16 5 <br />2. Recaltllerld Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br />V11. REVIEW EVALUATION - TO HE COMPLETED BY A SUPERVISOR/SENIOR <br />-ONCUR WITH SIAff RECOMMENDATION FOR CLOSURE <br />ES <br />O <br />EFERREO 10 SITE MITIGAf10N FOR EVALUATION <br />ES <br />0 <br />ATE REFERRED <br />/ / <br />ATE CLOSURE LETTER MAILED <br />AME OF <br />VALUATOR <br />Ln 43 ou (uul WK5HI)\5/v0 <br />