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SAN JOAGUI &NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HQ DIVISION <br />I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br />AME OF FACILITY1NYI'>*ri�I A WEEPS CODE <br />nnooee <br />-7 4A G i ANK ID # <br />�tANK SIZE I /V; WW 2 IFUEL TYPE <br />If. GENERAL SITE HISTay <br />permit <br />current? <br />es <br />o <br />o <br />ailed precision test ? <br />ermit # <br />Itof/Yeor <br />o <br />acility <br />Status Code <br />4 <br />as a repair made to the tank system? Yes No f yes, what was repaired? <br />oc.SoiL/GW <br />Cont <br />es <br />If <br />ere soil samples anaLyzed? es <br />!o <br />ftr of <br />Tanks at <br />facility <br />I <br />PH•G <br />Be of Tanks(if <br />available) <br />b/EDO <br />Score <br />10 pts <br />if <br />ondition <br />is met <br />ype of Tank <br />teel <br />atastrophic <br />FbrgL <br />istance to Wells) from Tank <br />ngl L <br />Dual <br />as Tank tested? <br />as <br />o <br />IF <br />ailed precision test ? <br />as <br />If <br />Itof/Yeor <br />o <br />verage Annuat Precipitation <br />If yes, give date(s) <br />4 <br />as a repair made to the tank system? Yes No f yes, what was repaired? <br />)n -Site Welt(s) <br />ns repair time under inspection? <br />Yes No <br />ere soil samples anaLyzed? es <br />Io I <br />TXE <br />I <br />PH•G <br />I <br />PN -D <br />b/EDO <br />Score <br />10 pts <br />if <br />ondition <br />is met <br />Type of failure/discharge <br />Score <br />9 pts <br />condition <br />is met <br />atastrophic <br />long-term Leakage <br />istance to Wells) from Tank <br />verfilL <br />nknown <br />I <br />iother: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />soil Samples Received <br />as <br />o <br />epth to Ground Water <br />I <br />Itof/Yeor <br />10 <br />verage Annuat Precipitation <br />k= <br />4 <br />10.25 <br />)n -Site Welt(s) <br />as <br />o <br />umber 8 Type <br />Irr <br />I <br />om I <br />ub <br />S <br />C <br />0 <br />R <br />E <br />Score <br />10 pts <br />if <br />ondition <br />is met <br />S <br />C <br />0 if <br />R <br />E <br />Score <br />9 pts <br />condition <br />is met <br />S <br />C <br />0 <br />R <br />E <br />3core <br />5 pts <br />if <br />ondition <br />is met <br />istance to Wells) from Tank <br />ft; ft; ft <br />Site Feature . Leaching Potential Analysis <br />inimun Depth to groundwater from the Soil Sample (feet) <br />>100 <br />1.100 <br />25-50\1 <br />ractures in subsurface (applies to foothills or mountain areas) <br />None <br />Unknown <br />resent <br />verage Annual Precipitation (inches) <br />KXXXXX <br /><10 <br />9 <br />10.25 <br />xxxxxxx <br />26.40\2 <br />an -Made conduits Which increase vertical migration <br />f leachate (i.e., septic systems, water wells, ponds) <br />None <br />Unknown <br />Dresent <br />lnique site features: Recharge area, coarse soil, nearby wells. <br />xxxxx <br />None <br />At least <br />one <br />lore than <br />one <br />COLUMN TOTALS»>TOTAL POINTS <br />+ <br />7 <br />.>T(� <br />_� <br />ampLe Result: (B T X OR E) <br />Nab PP"' <br />RANGE OF TOTAL POINTS <br />9 pts or more <br />41 48 pts <br />40 pts or Less <br />MAXIMUM ALLOWABLE B•T•X-E LEVELS (PPM) <br />50 <br />50 50 <br />.3 <br />.3 <br />X <br />1. <br />E <br />1. <br />NA\3 <br />So Le esu lt: L, <br />/w-T40A <br />(� TPH <br />fe <br />ASOLINE <br />ALLOWABLE TPH LEVELS (PPM) <br />fESEL <br />1000 <br />100 <br />10 <br />10,000 <br />1000 <br />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 Contami nation 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 BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br />VI. STAFF RECOMMENDATION/CONCLUSION �I'V e 1n� I1 /477T <br />1. Are BTX 8 E or TPH Concentrations > AlLowabl evels Yes o <br />19 <br />2. Recommend Site Closure 1Yes o !f 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 <br />ES <br />0 <br />EFERRED TO SITE MITIGATION FOR EVALUATION <br />ES <br />10 <br />ATE REFERRED <br />/ / <br />ATE CLOSURE LETTER MAILED <br />AMEOF <br />:VALUATOR <br />I� <br />EN 23 80 (UGTWKSHT)\5/90 <br />EH 29 80 <br />