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SAN JOAOUI ANTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H0 DIVISION <br /> 1, UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE ,� 2/ % <br /> AME OF FACILITY < L G2'�-F�y1 WEEPS CODE (8'O <br /> ODRESS 99.40E ''me- STyee+ tool CA CJS�c/0 ANK ID p o - <br /> ANK SIZE 10,oyvD d_EUEL TYPE <br /> 11. GENERAL SITE HISTORY ww <br /> Is permit current? as IF acility Status Code oc.Soil/GW Cont es o <br /> 1-1 <br /> umber of Tanks at facility PeofTanks(if available) ANK. ype of Tank ISteel Fbrgl ngl Dual <br /> ITT. TANK HISTORY <br /> 'as Tank tested? as o ailed precision test ? as 0 If yes, give date(s) <br /> as a repair made to the tank system? as No XC f yes, what was repaired? <br /> ns repair done under inspection? as o ere soil samples analyzed? es to T%E PH-G PM-D b/EDD <br /> ype of failure/discharge atastrophic long-term leakageverfilnknown cher: <br /> l x <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> .oil Samples Received es o epth to Grovel Water of/Year N8 fn verage Annual Precipitation = 4 10-25 <br /> n•Site WeLI(S) as o ( umber & Type I Irr I ub <br /> S <br /> core 5 Score S Score <br /> istance to WeIL(s) 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 net E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) ��Y >100 1-100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) Ia None Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 xxxxxxx 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 /> Inique site features: Recharge area, coarse soil, nearby Wells. At Least lore than <br /> xxxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS C� �� + <br /> 'ample Result: (B T % OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> .� � mkcts.�e B T X. E <br /> lip 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 /> A%IMUTA ALLOWABLE TPH LEVELS (PPM) IG <br /> u�w� ID,r�'PIY'H IESEL 10,000 1000 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 /> 71 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes I IHOI <br /> 2. Recommend Site Closure 1Y <br /> es 0 If Yes, Refer to Site Mitigation for Evaluation �%n- <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 EVALUATIONES JO <br /> ATE REFERRED ITATE CLOSURE LETTER MAILED <br /> 4AME OF <br /> .VALUATOR L / <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />