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SAN J COUNTY PUBLIC HEALTH SERVICES/ENVIRONMEN EALTH DIVISION <br /> I• UGST WORKSHEET FOR SITE CLOSURE EVALUATE( ATE 1a-�a_5,o <br /> AME OF FACILITY <br /> /C/nL WEEPS CODE <br /> DRESS / E / /,I L ANK 10 N <br /> �-- <br /> ANK 512E �/DD UEL TYPE Ae/ o,/ <br /> 11. GENERAL SITE HIST R <br /> Is permit current? es o V/ ermit q - acility Status Code s3 ac.Soi l/GW Cont as o <br /> ua�ber of Tanks at facility ge of Tanks(if eve table) ype of Tank teel Fbrgl Dual <br /> 111. TANK HISTORY <br /> as Tank tested? as o ailed precision test ? as o If yes, give date(s) <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> as repair done under inspection? as 0 ere soil samples analyzed? es o TXE PH•G PH-D b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfill noun ther: <br /> IV. REMOVAL HISTORY (ATTACH 1NSPE5ION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Receive!M <br /> es o epth to Ground Water 100 of/Year /�j�-;� verage Annual Precipitation <br /> 3n-Site Wallis) es 0 umber 8 Type Irr ub <br /> S core S core S core <br /> istance to Welts) from Tank `/C7 ft; ft; ft c 0 pts C pts cis <br /> 0 if 0 if 0 'fp <br /> R onditiol R Onditien R Ondltion <br /> Site Feature - Leaching Potential Analysis E is met E is met E 's met <br /> inimun Depth to groundwater from the Soil Somple (feet) >100 1-100 25-50,.1 <br /> ractures in subsurface (applies to foothills or mountain areas) None unknown <br /> resent <br /> verage Annual Precipitation (inches) xxxx <10 9 10-25 xxxxxx 26-40•.2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None 9 Unknown resent <br /> nique site features: Recharge area, coarse soil, nearby wells. At leastr ore than <br /> xxxx None one J one <br /> COLUMN TOTALS»>TOTAL POINTS + <br /> ample Result: (B T % OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or Less <br /> r ✓n B T X E B T X E <br /> MAXIMUM ALLOWABLE B-T•X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA1 <br /> ample Result: ASOLINE 1000 100 10 <br /> IHJM ALLOWABLE TPM LEVELS (PpM) <br /> /0 m TPH 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 /> 1? if precipitation is > 40 inches, score 0 points. <br /> L Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes 0 <br /> 2. Recommend Site Closure es oVl�lf Yes, Refer to Site Mitigation for Evaluation <br /> V11. 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 0 <br /> ATE REFERRED ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR 0 . O Z <br /> EH 23 80 (UGTWKSHT)\5/90 <br />