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SAN JOAOUIRUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL OR DIVISION <br /> I UGST WORKSHEET FOR SITE CLOSURE EVALUATION AT <br /> EEPS CODE <br /> AME OF FACILITY <br /> \^ ANK ID # <br /> DDRESS tV / <br /> ANK SIZE <br /> UEL TYPE <br /> �11. GENERAL SITE HISTORY Z l 00d d I� <br /> I permit current? as o ermit # acility <br /> Status Code oc.Soi l/GW Cont es o <br /> umber of Tanks at facility 9 <br /> e of Tanks(if available) ype of Tank reel Fbrgl ngl Dual <br /> III. TANK HISTORY <br /> Aif <br /> Tank tested? as o ailed precision test ? as o Y , 91111141 dates) <br /> as a repair made to the tank system? as No f yes, what was repaired? <br /> ns repair done under inspection7 OR o ere soil samples analyzed? as to T%E PH•G PH•D b/EDD <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 /> oil Samptea Received as 0 epth to Ground Water f (4) of/Year /R-&; verage Annual Precipitation Nz 4 10.25 <br /> •St to Welt(s) as o umber & Type Irr om ub <br /> S core S 3core <br /> istance to Wells) from Tank ft; ft; ft C 0 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R ondition Rotditi on R ondition <br /> . Site Feature - Leaching Potential Analysis E •a met E is met Es 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 xxxxxx 26-40\2 <br /> an-Made con"is which increase vertical migration - <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 (ore than <br /> xxxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS to + <br /> �8 Ample Result: (D T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 • 48 pts 40 pts or less <br /> �i NDa'j- �w �� <br /> 1 n�AnK'z ANS CLf' •0 f B T X E B T X. E <br /> MA%I MINI ALLOWABLE 0•T•X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Cff ample esult: ASOLTNE, 1000 100 10 <br /> 1 AXIMUM ALLOWABLE TPH LEVELS.(PPM) <br /> 10vZ(1X�a* l.opP Tpg_ IESEL. 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the teaching 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 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 TPM Concentrations > Allowable Levels Yes I IN01 <br /> 2. Recommend Site Closure as o 1 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 <br /> _VALUATOR `7 U <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> Et 29 80 <br />