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SAN JOAOCOUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTALIP.ALTH DIVISION <br /> )• UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> AME OF FACILITY \/\j,W . WEEPS CODE z3SZ <br /> DRESS 20$5I SGwt1--1 SL.)f-( l{-{ 1E-SceiCG ) ANK ID # 39-- <br /> TANK <br /> q=ANK SIZE 56 <k UEL TYPE l<2 L,5 <br /> 11. GENERAL SITE HISTORY <br /> *R <br /> Is permit current7 es o ermit # - acility Status Code cJ p oc.Soil/GW Cont as o <br /> umber of Tanks at facility ' ge of Tanks(if available) ype of Tank teel brgl ngl Dual <br /> 111. TANK HISTORY <br /> -FA.nk r¢.rno,)ed 5.25.$`1 <br /> as Tank tested? ks o ailed precision test ? as o If yes, give date(s) <br /> Jas a repair made to the tank system? as No f yes, what was repaired? <br /> as repair done under inspection? eso ere soil samples analyzed? es TXE PH-G PH-D I b/EDB <br /> Type of failure/discharge ata strophic long-term leakage vert iI! nknown ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es o epth to Ground Water of/Year ; $i� verage Annual Precipitation = 4 0-25 <br /> n-Site WeLI(S) es ✓ o I -I umber & Type Irran ub <br /> S Score S core S core <br /> istance to Wells) from Tank yn{( ft; ft; ft C 10 pts C pts C pts <br /> 0 if 0 1f 0 f <br /> R ondition R ondition R ondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E s met <br /> inimum Depth to groundwater from the Soil Sample (feet)_;'5- cf 44 >100 1-100 25-501 <br /> Fractures in subsurface (applies to foothills or mountain areas) 'i I O None Unknown resent <br /> verage Annual Precipitation (inches) xxxx <10 9 10-25 xmxmx 26-4012 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) go—, Note Unknown 5 resent <br /> pique site features: Recharge area, coarse soil, nearby wells. At least 4ore than <br /> xxxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS �(] a I <br /> ample Result: (B T % OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> ND PPM B 1 TE B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NAL <br /> ample Result: ASOLINE 1000 100 10 <br /> N IO AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> PP�ITPH 0 IESEL 1 10,000 1000 100 <br /> OOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the leaching potential <br /> am Lysis. (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 /> 12 If precipitation is > 40 inches, score 0 points. <br /> 13 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION NO ric" Q , <br /> -ftw .nF <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure as o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 I EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF �--�'7 <br /> VALUATOR / / <br /> EH 23 80 (UGTWKSHT)\5/90 <br />