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SAN JOAOU&NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL OTH DIVISION <br /> I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY Gs F WEEPS CODE <br /> ODRESSl'�'od / ��Cd /" t."C 7?�t�/�� TANK ID # Pel<ct') <br /> TANK SIZE _1 (�� UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> ** <br /> Is permit current? es o ermit # acility Status Code oc.Soil/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tank Leel Fbrgl Dngt Dual <br /> ill. TANK HISTORY <br /> as Tank tested? es o ailed precision test ? es o 1f yes, give date(s) <br /> as a repair made to the tank system? Yes No 11f yes, what was repaired? <br /> ns repair done under inspection? es o ere soil samptes analyzed? 1Y <br /> es Jo TXE PH-G PH-D b/EDB <br /> ype of failure/discharge atastrophic long term leaks' e verfilt mknown ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILSI/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> soil Samples Received esepth to Ground Water 'i-� of/Year 1Li� 7 verage Annual Precipitation <br /> o = 4 10 25 <br /> n-Site Welt(s) 1Y <br /> es I o I umber & Type Irr ' om ub <br /> _ y/ S Score S Score S Score <br /> Distance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R condition R condition R condition <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 /> average Annual Precipitation (inches) XXXXXX <10 9 10-25 xxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> Df 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 /> xxxxx None 9 one one <br /> COLUMN TOTALS>>>TOTAL POINTS + L _a <br /> 'ample Result: (B T X OR E) RANGE OF TOTAL POINTS +9 pts or more 41 - 48 pts 40 pts or less <br /> �'\ e '� ff'ir\ I B T B T X E ___MAXIMUM ALLOWABLE B-T-X-E LE ELS (PPM) 1 50 [XE <br /> 0 .3 .3 1. 1. NA\3 <br /> -ample Result: ASOLINE 1000 100 10 <br /> l\� � wcfi AXIMUM ALLOWABLE TPH LEVELS (PPM <br /> 1 TPH IESEL 10,000 1000 --_.__. 100 i <br /> FOOTNOTES: ***If documented soil and/or ground water c tamination is present, do not complete the leaching potential <br /> 1 21'*' analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> �efL°1 \1 if depth is > 5 ft. and < 25 ft., score 0 points. If depth r_5 ft., do not use table. <br /> �6M7is ��p \2 If precipitation is > 40 inches, score 0 points. <br /> t \3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes o C'1- ( /� <br /> 2. Recommend Site Closure es I INO <br /> If Yes, Refer o Site Mitigation for Evaluations �J <br /> VII, REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SEN10 <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE fES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 1 40 <br /> ?ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> :VALUATOR <br /> i <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />