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1b <br /> SAN JOA(XUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> I, UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AI(E OF FACILITY 4'7 /� WEEPS CODE ��Cr <br /> DRESS 4�I J� �7 f_t TANK ID f! `pct • ?j '_ <br /> TANK SIZE I ti UEL TYPE ora <br /> II. GENERAL SITE HISTORY <br /> Is permit current? es I lNoi ermit p - acility Status Code 1, <br /> oc.S it/GW Cont es o <br /> umber of Tanks at facility ge of Tanks0 f available) :' ype of Tank teelYI <br /> Fbrgl I ngl Dual <br /> III. TANK HISTORY <br /> Jas Tank tested? es 1,401 ailed precision test 7 eso 7-jif yes, give date(s) <br /> as a repair made to the tank system? es No Ef f yes, what was repaired? <br /> as repair done under inspection? es o ere soil samples analyzed? es o 3TXE PH-G PH-D b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfill nknown thcr: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es o I epth to Ground Water ,—j of/Year w; verage Annual Precipitation 4 0-25 <br /> Site WeIL(s) es o umber & Type lir r om ub <br /> 5 3core S Score S 3core <br /> istance to Wells) from Tank ft; ft; ft G 10 pts C 9 pts C i pts <br /> 0 if 0 if 0 if <br /> R ondition R condition R ondition <br /> J. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Sail Sample (feet) >100 1-100 =� 25-50,' 1 <br /> racture& in subsurface (applies to foothills or mountain areas) None Unknown Present <br /> verage Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxx 26-402 <br /> an-Made conduits which increase vertical migration <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 4ore than <br /> xxxx None one one <br /> COLUMN TOTALS—TOTAL POINTS * c{. <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or Less <br /> 8 1 T K E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA,L3 <br /> ample Result: ASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> <? TPH Lkytc,—r1000` IESEL 10,000 1000 100 <br /> OOTN07ES: **"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 /> N2 If precipitation is > 40 inches, score 0 points. <br /> L Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes o �; �'� � �i E bili t�f}:c• �4UAvti f'�k Llv�Zs <br /> 2. Reco wnd Site Closure es o If Yes, Refer to Site Mitigation for Evaluation IF "F-1-ft5 FV—E Oyu - <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE fES o EFERRED TO SITE MITIGA710H FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> _VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />