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SAN JOAQUININTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HIPH DIVISION c} <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE (2— 3 6 L,3 <br /> AME OF FACILITY C�i�' u WEEPS CODE <br /> ADDRESS A d-5o o v ANK ID # <br /> TANK 5I2Eop-0 UEL TYPE <br /> It. GENERAL SITE HISTORY <br /> Is permit current? as I liol ermit # I IFacility Status Code oc.Soil/GW Cont as Jo <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tank Leel lFbrgl I Isngl I Duall <br /> III. TANK HISTORY <br /> as Tank tested? es 1HQ1 ailed precision test ? es o If yes, give date(s) <br /> as a repair made to the tank system? as No 11f yes, what was repaired? <br /> ns repair done under inspection? as o ere soil samples analyzed? es 10 TXE PH•G PH-D b/EDG <br /> Type of failure/discharge atastrophic long-term leakage verfill nknown ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Ail Samples Received as I o epth to Ground Water 16O of/Year lAverage Annual Precipitation A= 11 <br /> 4 10-25 <br /> 3n-Site Wells) as o umber 8 Type Irr I om I ub <br /> S Score S Score S 3core <br /> istance to Wells) from Tank it; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R onditi on R conditi on R ondition <br /> V. 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) 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 /> lnique site features: Recharge area, coarse soil, nearby wells. At least 4ore than <br /> xXXhx�x None one one <br /> COLUMN TOTALS>»TOTAL POINTS I v + �� + T <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or less <br /> �P�` G T---[XT X E B T X E <br /> N D 1N MAXIMUM ALLOWABLE B•T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> 3ampLe ROSWIt� ASOLINE 1000 100 10 <br /> ��-- ' AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> N � TPH ' IESEL 10,000 1000 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 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 TPH Concentrations > Allowable Levels Yes I IN01 <br /> 2. Recommend Site Closure FesT o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION . TO BE C014PLETED BY A SUPERVISOR/SENIOR <br /> RE 'ES '0 <br /> -ONCUR WITH STAFF RECOMMENDATION FOR CLOSUEFERRED TO SITE MITIGATION FOR EVALUATION ES JO <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> :VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />