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SAN JOAOCOUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAALTH DIVISION q <br /> 1, UGST WORKSHEET FOR SITE CLOSURE EVALUATI ATE <br /> AME OF FACILITY po ve—�Gro LIEEPS CODE Z.7jz g' <br /> DRESS 21 -�-fQ `j, MCL,— ATvn'1LJ ✓ ANKIDtY 3`7=Z3z�I- �� <br /> TANK SIZE 5 Q UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? as o ermit p - acility Status Code 5) oc.Soi t/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) U V\,��- ype of Tank teel Fbrgl ngl Dual <br /> 111. TANK HISTORY y'epvLOJe Q.23• T$r <br /> as Tank tested? es o ailed precision test ? es o ✓if yes, give date(s) <br /> Jas a repair made to the tank system? es No f yes, what was repaired? <br /> as repair done under inspection? <br /> as o ere soil samples analyzed? es TXE <br /> Type of failure/discharge atastrophic long-term leakage [!ver f ill noun I lother: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received as o epth to Ground Water of/Year verage Annual Precipitation = 4 0-25 <br /> )n-Site WeIL(s) es o umber 8 Type Irr om ub <br /> S Score S Score S Score <br /> istance to Wel l(s) from Tank I 0+ —ft; ft; ft C To pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R ondition 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) /nom -100 1.100 25.5031 <br /> Fractures in subsurface (applies to foothills or mountain areas) b None Unknown Dresent <br /> verage Annual Precipitation (inches) xxxx <10 9 10-25 xxxx 26-401 <br /> an-Made conduits which increase vertical migration c <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown J resent <br /> pique site features: Recharge area, coarse soil, nearby wells. At least 4ore than <br /> xxxxx None one one <br /> » �I <br /> COLUMN TOTALS >TOTAL POINTS ID [� � I+ l + G Q <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or Less <br /> W411, <br /> or' ,o817Ey pl+n A) ntB T X E B T X E <br /> yPP MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NAL <br /> Sample Result:C ASOLINE 1000 100 10 <br /> N D � n AKIWJM ALLOWABLE TPN LEVELS (PPM) <br /> ?PM TPH 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 /> 31 If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> 1 If precipitation is > 40 inches, score 0 points. <br /> L Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION /Jo e0r1 WIitlr'w, ✓V7d-e <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable LevelsYes opr <br /> 2. Recommend Site Closure es o if Yes, Refer to Site Mitigation for Evaluation <br /> VII. 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 � CT <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />