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SAN JOAOUARUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL GTH DIVISION <br /> 1• UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY <br /> /r WEEPS CODE <br /> DRESS 9'� 7 n; '7� TANK ID p - <br /> TANK SIZE UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? es o ermit # - acitity Status Code oc.Soil/GW Cant es o <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tank Leel Fbrgl rgl Dual <br /> III. TANK HISTORY <br /> as Tank tested? es I 1H <br /> o aited precision test 7 es o If yes, give <br /> as a repair made to the tank system? Yes No f yes, what was repaired? <br /> as repair done under inspection? es No ere soil samples analyzed?F <br /> es o I TXE PH-G PH-D b/EDB <br /> Type of failure/discharge atastrophic long-term Leakage verfill known ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es I IHOI epth to Ground Water I `-. of/Year - verage Annual Precipitation 4= 4 0-25 <br /> -Site Wells) es I o I umber & Type Irr om ub <br /> S score S Score S 3core <br /> istance to We(L(s) from Tank ft; ft; ft C 10 pts C 9 pts C i pts <br /> 0 if 0 if 0 if <br /> V. R condition R condition R ondition <br /> Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet)t .. >100 1-100 '`i 25-5OL <br /> Fractures in subsurface (applies to foothills or mountain areas) More Unknown resent <br /> verage Annual Precipitation (inches) xxxx 00 9 10-25 xxxx 26-40L <br /> an-Made conduits which increase vertical migration s <br /> f leachate (i.e., septic systems, water welLs, ponds) None Unknown ,� resent <br /> pique site features: Recharge area, coarse soil, nearby wells. At least 40re than <br /> xxxx None one S one <br /> COLUMN TOTALS»>TOTAL POINTS . + - <br /> �l <br /> ample/Result: (B T X OR E) RANGE OF TOTAL POINTS9 pts or more 41 - 48 pts 40 pts or less <br /> B T X E B T E <br /> �2 r+ <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA13 <br /> ample Result: SOLINE 1000 100 10 <br /> n -F E n.j I/ IMl1N ALLOWABLE TPH LEVELS (PPM) <br /> �l.l I TPp IESEL 10,000 1000 100 <br /> OOTNOTES: ***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 /> L If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> L If precipitation is > 40 inches, score 0 points. <br /> L Levels for BTX&E are not applicable at a TPM concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are 8TX & E or TPH Concentrations > Allowable Levels Yes o <br /> I2. Recommend Site Closure IYes I O 7' I* 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 ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES I 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 �l <br />