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SAN JOAGURICIOUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE �1 p <br /> qME OF FACILITY EEPS CODE <br /> DDRE BS ANK ID p <br /> ANK SIZE UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> x* <br /> Is permit current? es o ermit q acility Status Code oc.Soil/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tank teel Fbrgl I ISngl Dual <br /> 111. TANK HISTORY <br /> as Tank tested? es o ailed precision test ? as o If yes, give date(s) <br /> Jas a repair made to the tank syigt:Eere <br /> asNo f yes, what was repaired? <br /> ns repair done under inspectionas <br /> soil samples analyzed? Rnknown' <br /> o T%E PH•G ype of failure/discharge atastrophie long-termleakage verfill they: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/C,LLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received as o epth to Ground Water ' of/Year ;�8� verage Amual Precipitation k= 4 10-25 <br /> -Site Wett(s) as 0I umber 8 Type Irr om ub I fl <br /> S Score S Score s core <br /> istance to wetl(s) from Tank ft; ft; ft C 10 pts C 9 pts C i pts <br /> 0 if 0 if 0 'f <br /> R onclition R condi t1 on R ondition <br /> Site Feature - Leaching Potential Analysis �/, (3 E is met E is met E 's met <br /> inimum Depth to groundwater from the Soil Sade (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 ,xxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration 9 <br /> f leachate (i.e., septic systems, water wells, ponds) None / Unknown >resent <br /> inique site features: Recharge area, coarse soil, nearby wells. At least lore than <br /> xxxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS IQ • a ♦ <br /> ample Result: (B T X OR E RANGE OF TOTAL POINTS F9 pts or more 41 - 48 pt 40 pts or less <br /> STYX ND�;.oIP�., <br /> B 1 T I X E B T X E <br /> MAXIMUM ALLOWABLE B-T•X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> 'ampl e,,yyRcsult:J 5P ASOLINE 1000 100 10 <br /> . p I0 AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> °�F If IESEL 10,000 1000 100 <br /> OOTNOTES: ***If documented soil and/or ground water contamination is present, do of complete a leaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List f soil 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 o <br /> I2. Recommend Site Closure res Il/�O I �'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 00 1 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF I 7 <br /> .VALUATOR 4' <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />