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r <br /> SAN JOAGUINRNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL A DIVISION <br /> i. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE 36 7'3 <br /> AME OF FACILITY �a1n1,n, EEPS CODE D <br /> DDRESS ) 17�sC� �-rY1 ANK ID # <br /> TANK SIZE boon 1 L(Oda UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> Is permit cuo ermit # acility Status Code oc.Soil/GW Cont es 10 <br /> rrent? es <br /> umber of Tanks at facility he of Tanks(if available) IType of Tank IStest Fbrgl I ISngl Dual <br /> III. TANK HISTORY <br /> as Tank tested? es IFailed precision test 7es o If yes, give date(s) <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> ms repair done under inspection? es o ere soil samples analyzed? es !o TXE PH•G PP•D b/EDD <br /> ype of failure/discharge atastrophic long-term leakage verfill nknown 1 10cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Sall Samples Received es I o epth to Ground Water CEO of/Year tcap; INverage Annual Precipitation = 4 10.25 <br /> )n-Site Wells) IYes o umber & Type Irr am 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 ondition 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) L40— 15- 5 >100 1.100 S 25.50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) to None Unknown rresent <br /> verage Annual Precipitation (inches) xxxxxx <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) ' 1 0 None Unknown resent <br /> Inique site features: Recharge area, coarse soil, nearby wells. At least lore than <br /> xxxxx None r� one One <br /> lap <br /> COLUMN TOTALS>>>TOTAL POINTS * * <br /> ample ResVVult: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 is 40 pts or Less <br /> !8 I mo/ `N-P 04, 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. NA\3 <br /> Sample ResuA�t: '��} ASOLINE 1000 100 10 <br /> TDD � l PP" IAXIKJM ALLOWABLE TPH LEVELS (PPM) <br /> 6 eLnPN a IESEL 10,000 100 <br /> FOOTNOTES: ***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 BTX&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 & E or TPN Concentrations > Allowable Levels Yes I IHOI <br /> 2. Recomend Site Closure as I o If Yes, Refer to Site Mitigation for Evaluation <br /> V11. 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 / / n ATE CLOSURE LETTER MAILED <br /> AME OF <br /> -VALUATOR <br /> EH 23 60 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />