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SAN JOAOUINONTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> qME OF FACILITY 0. EEPS CODE <br /> DDRESS ANK ID M <br /> TANK SIZE �� UEL TYP <br /> II. GENERAL SITE HISTORY <br /> Is permit current? es o ermit # acility Status Code oc.Soi US Cont es Io <br /> umber of Tanks at facility Be of Tanks(if available) ype of Tank Leel Fbrgl ngl Dual <br /> Ill. TANK HISTORY <br /> as Tank tested? es I IHOI ailed precision test ? es o If yes, give date(s) <br /> Jas a repair made to the tank system? as No 1 11f yes, what was repaired? <br /> ms repair done under inspecti on7 es o ere soil samples analyzed? as Io 1 13TXE PH•G PH-D b/EDB <br /> ype of failure/discharge atastrophic Long-term leakage verfill nknown 1 10 <br /> ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es oepth to Ground Nater is of/Year (* ; verage Annual Precipitation 4 10-25 <br /> On-Site Welts) es o umber 8 Type Irr I am I ub <br /> S Score S Score S Score <br /> istance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R conditi on R conditi on R ondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) S— Q,S >100 1-100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) I None Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 KXXXXXX 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> lnique site features: Recharge area, coarse soil, nearby wells. At leastore than <br /> xxxxx None one S one <br /> COLUMN TOTALS>>>TOTAL POINTS b * I t -5 �} <br /> ampl efT\\Ras (B T % OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> CLult:I a" P m � 0 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\3 <br /> ample Result: ASOLINE 1000 100 10 <br /> ,`D e I(7 Q� d A%IMUM ALLOWABLE TPH LEVELS (PPM) <br /> N_�TPH" IESEL. 1 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 /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for 8TX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure as o If Yes, Refer to Site Mitigation for Evaluation L7 I U <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 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> -VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />