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SAN JO COUNTY PUBLIC HEALTH SERVICES/ENVIRONNENOEALTH DIVISION <br /> 1' UGST WORKSHEET FOR SITE CLOSURE EVALUATIuN <br /> ATE /a-/d.—90 <br /> AME OF FACILITY _ <br /> 6/G/q WEEPS CODE /e0s— <br /> DRESS ' H /,-J ITANIC ID # <br /> ANK SIZE >Q2 UEL TYP an_ <br /> 39 • /dos — v3 <br /> �/'gCIPc 'tzS <br /> 11. GENERAL S1TE HIST RY <br /> kf <br /> Is permit current? as o ermit # ecili[y Status Code S3 oc.Soil/GW Con[ es o <br /> uh:er of Tanks at facility ge of Tanks(if available) <br /> ype of Tank Leel Fbrgt PnWq Dual <br /> 111. TANK HISTORY <br /> Rypeof <br /> ested? aspatastrochic <br /> cision test ? as o If yes, give date s) <br /> ir made to thas No f yes, what was repaired? <br /> done under iaso ere soil samples analyzed? es o TXE PH-G PH-D b/EDB <br /> ilure/discharlong-term Leakage"ill nown Cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received as o epth to Ground Water �p' of/Year 9 �E verage Annual Precipitation = 4 0-25 <br /> -Site Wells) as o umber & Type .Z Irr om ub <br /> istance to wells)) from Tank /(7J fq S tore S core S core <br /> ft; ft C 0 pts C pts C pts <br /> 0 if 0 f 0 f <br /> R ondi tion R ondition R ondition <br /> Site Feature - Leaching Potential Analysis E is met E is nhe[ E is met <br /> inimum Depth to groundwater from the Soil Sanple (feet) >100 1.100 25-501 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) xxxx <10 9 10-25 xxxxxx 26-4012 <br /> an-Made conduits Which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown 57— resent <br /> niclue site features: Recharge area, coarse soil, nearby wells. At least <br /> xxx None ore than <br /> x <br /> one j one <br /> COLUMN TOTALS>>>TOTAL POINTS + t <br /> ample Result: TO T % OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> B 1 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: SOLINE 1000 100 10 <br /> lMUN ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> DOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the teaching <br /> analysis. (i.e., site Is currently on UGT Contamination List for soit or ground water.)�t potential <br /> 1 If depth is > 5 ft. and < 25 it., score O points. If depth <=5 ft., do not use table. <br /> 1? 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). I <br /> V1. STAFF RECOMMENDATION/CONCLUSION } <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes o 6 <br /> I2. Recommend Site Closure as I ,/fJo I pIf Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MI TI CATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSH1)\5/90 <br /> a <br />