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SAN JOAOUINYOUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HIT6H DIVISION <br /> I, UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY y X.. V J WEEPS CODE <br /> ANK ID # <br /> TANK SIZE UEL TYPE <br /> II. GENERAL SITE HISTORY <br /> Is permit current? as o ermit # acility Status Code LLLL oc.Soil/GW Cant es 10 <br /> umber of Tanks at facility Be of Tanks(if available) ype of Tank pteel I IFbrgl I �ngll Dual <br /> III. TANK HISTORY c I <br /> 'ns Tank tested? es o ailed precision test ? 'es o If yes, give date(s) <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> as repair done under inspection? es o ere soil samples analyzed? es to ITTXE PH-G PH-D I b/EDB <br /> ypa of failure/discharge ata <br /> strophic long-term leakage verf ill nknown cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> ,oil Samples Received as o epth to Ground Water of/Year ; verage Annual Precipitotion = 4 10-25 <br /> 3n-Site Wells) as I lid <br /> umber 8 Type Irr I ub <br /> S core S core 5 core <br /> istance to Wells) from Tank ft; ft; ft C 10 pts C pts C pts <br /> 0 if oif o 'f <br /> R ondition R ondition R onditi on <br /> V. Site Feature - Leaching Potential Analysis E is met E is met Es met <br /> inimum Depth to groundwater from the Soil Sample (feet) 1( ,Z� a LI >100 1-100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) r None Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 Axxxxxx 26-40\2 <br /> an-Made Conduits which Increase vertical migration <br /> f leachate (i.e., septic systems, water wails, 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 + + <br /> 'ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> X Z Pry G T X E B T % E <br /> 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%IMUM ALLOWABLE TPH LEVELS (PPM) <br /> h TPN 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 BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPN Concentrations > Allowable Levels Yes <br /> 2. Recommend Site Closure es 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 / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> :VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />