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/—,A-'// <br />SAN JOADU... COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL Ir�ALTH DIVISION <br />1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE �IAM/ — <br />E OF FACILITY//LL / y� �-1 WEEPS CODE <br />DRESS 1'q q 7 / 7). i. f, k�i9,n .+. /�!/` - ANK IDM 4q-1 <br />�'— <br />(ANK SIZE 1 00 o UEL TYPE <br />I1. GENERAL SITE HISTORY <br />Is permit current? ifes No <br />Iniber of Tanks at facility <br />111. TANK HISTORY , <br />t 9 13c/ - D41135 taciLity Status Code I �) / poc.Soil/GW Gant res I r <br />ge of Turks( If available) I /�I' Ilyp. 'of Tank teal kAbrgt nal I Duel <br />Jos Tank tested? <br />Ifes <br />I <br />IHQ <br />ailed precision test ? <br />Itas <br />of/Year <br />o <br />If <br />yes, give date(u) <br />4 <br />Ads a repair node to the tank system? as No <br />f yes, what was repaired? <br />11 eso <br />Ada repair done under Inspection? <br />as o <br />ere soil smplas analyzed? <br />Yes <br />o <br />/ / <br />TXE <br />I <br />PR -G <br />IT <br />S <br />c <br />0 <br />Rondition <br />E <br />PH -D <br />S <br />C <br />0 <br />N <br />E <br />b/EDO <br />S <br />C <br />0 <br />R <br />E <br />We of failure/discharge <br />istonce to Wells) from Tank <br />atastrophic <br />Lane•term leakageverf <br />i. Site Feature - Leaching Potential Analysis <br />ill <br />mown <br />ther: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />Suit Salples Received <br />es <br />o <br />ep [h to Ground Nater <br />of/Year <br />verage Annual Precipitation <br />4 <br />0.25 <br />-Site WeLL(s) <br />11 eso <br />if,, <br />0 <br />umber Y Type <br />Irr <br />/ / <br />an <br />ub <br />S <br />c <br />0 <br />Rondition <br />E <br />3core <br />10 pts <br />if <br />is net <br />S <br />C <br />0 <br />N <br />E <br />score <br />9 pts <br />if <br />condition <br />is act <br />S <br />C <br />0 <br />R <br />E <br />Core <br />- pts <br />if <br />ondition <br />is mat <br />istonce to Wells) from Tank <br />it; Ft; �ft <br />i. Site Feature - Leaching Potential Analysis <br />ininsnn Depth to groudwa[er Fran the Soil Simple (feet) <br />>100 <br />51.100 <br />25.50j1 <br />fractures in subsurface (applies to foothills or mountain areas) <br />None <br />Unknown[ <br />resent <br />verage Annual Precipitation (inches) <br />xxxx <br />-10 <br />9 <br />10.25 <br />xxxxxx <br />26.40E <br />on•Made corxilits which increase vertical migration <br />f leachate (I.e., septic systans, water Hells, ponds) <br />None <br />Unknown <br />>resent <br />pique site features: Recharge area, coarse soil, nearby wells. <br />'xxxxxx <br />None <br />At leas[ <br />Ora <br />4ore than <br />one <br />COLUMN TOTALS»>TOTAL POINTS <br />'miple Result: (B T X OR E) <br />RANGE of TOTAL POINTS <br />9 pts or pore <br />41 - 48 pts <br />40 pts or less <br />MAXI MLN ALLOWABLE B-T-X•E LEVELS (PPM) <br />I <br />1 <br />T <br />50 <br />X <br />50 <br />E <br />50 <br />B <br />,1 <br />T x <br />.3 1. <br />E <br />1. <br />NA <br />mip(e Result: <br />TPH <br />IMUN ALLOWABLE TPN LEVELS (PPM) <br />IESEL <br />SOLINE <br />1000 <br />100 <br />10 <br />10,000 <br />BOB1 <br />100 <br />-OOINOIES: •••If docunented soil end/or ground water contaainotion is present, do not caiplete the leaching potential <br />analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br />1j If depth is > 5 ft. and c 25 ft., score 0 points. If depth <=5 ft., do not use table. <br />It precipitation is > 40 inches, score 0 points. <br />L Levels for 8TX1tE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br />VI. STAFF RECOMMENDATION/CONCLUSION <br />00 m�rccv� u 'fi1 p,� no � ��o ,��-u,,•j1_i1a�- , <br />1. Are BTX & E or TPH Concentrations Allo le Levels Yes o C"d/a(A <br />2. Reconiend Site Closure es I Vlfhf If Yes, Refer to Site Mitigation for Evaluation / <br />V11. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br />ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE <br />IfES <br />I <br />SITE MITIGATION FOR EVALUATION <br />if,, <br />0 <br />RED <br />/ / <br />ATE CLOSURE LETTER MAILED <br />R <br />ui a au %uulwxDnjj%ojvu <br />