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SAN JOAOU rDUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL c STH DIVISION p <br /> 1• UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE 12.26, I.3 <br /> AME Of FACILITY �Oct-1... j� viG ,y IS <br /> WEEPS CODE QC <br /> DDRESS AOI , 1 . JVVCt'�D-CVVU� 5+, 51 t� ANK ID # <br /> TANK SI2E �'T Iv UEL TYPE 3 5- 2005 . 01 . 31,ow tea <br /> 02 - y5o1, P -awtscJ <br /> 11. GENERAL SITE HISTORY Qg— 15W 9�a "'C"a <br /> toot .2 , (Rkc(aa ** <br /> Is permit current? es o ermit # acility Status Code -j1 oc.Soil/GW Cont es Jo <br /> Ember of Tanks at facility ge of Tanks(if available) Ln K [Type of Tank teel I Fbrgl I ngl I Dual <br /> III. TANK HISTORY I / <br /> as Tank tested? as IHOI 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 Jo 13TXE I ITPH-G I PH-D b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfill nknown 1 10ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> ,oil Samples Received es o epth to Ground Water of/Year verage Annual Precipitation 4= 4 10-25 <br /> )n-Site Wells) es ifo umber 8 Type Irr am ub <br /> S Score S Score S Score <br /> istance to Well(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 met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1.100 © 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) tp 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 /> ( leachate (i.e., septic systems, water wells, ponds) None '( Unknown resent <br /> Jnique site features: Recharge area, coarse soil, nearby wells. At least /-' ore than <br /> txxxxx None one "J one <br /> COLUMN TOTALS>>>TOTAL POINTS + + '5 33 <br /> Taor 'ample Result: (D T X OR E) RANGE OF TOTAL POINTS .9 pts or more 41 48 pts 40 pts or less <br /> �I(uOl=Nvh Bros �or�� <br /> <} q-00 EB B T X E B T X E <br /> MAXIMUM ALLOWABLE B-T•X•E LEVELS (PPM) 1 SO 50 50 .3 .3 1. 1. NA\3 <br /> 'ample Result: ASOLINEF1000 100 10 <br /> 2 DO " TPN AXIMUM ALLOWABLE TPH LEVELS (PPM) IESEL000 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 Pont (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> `jl�l.yt,8 5w�r.4c+(6• �.1 .Z f'Pn <br /> 1. Are BTX & E or TPN Concentrations > Allowable Levels Yes oVWC-*e-; <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> VI 1. REVIEW EVALUATION • TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> ,ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE 'ES '0 EFERRED TO SITE MIIYGATION FOR EVALUATION ES JO <br /> )ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> :VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> Ex 29 80 <br />