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SAN JOAWINONTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> NAME OF FACILITY , �( /i WEEPS CODE <br /> DDRESS <j �� ./ ^ n --�Gl�, ANK ID N <br /> TANK SIZE O UEL TYPE4 <br /> II. GENERAL SITE H TORY <br /> �w <br /> Is permit current? es o ermit p acility Status Code oc.Soi l/GW Cont as To <br /> umber of Tanks at facility ge of Tanks(if available) IType of Tank tee[ Fbrgl ngl I Dual <br /> III. TANK HISTORY <br /> 'as Tank tested? es I IN01 ailed precision test ? as 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 No ere soil samples analyzed? es to TXE PH•G PH-D b/EDB <br /> type of failure/discharge atastrophic long-term leakage verfill nknown 1 10Cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> .oil Samples Received as o epth to Ground Water l� of/Year verage Annual Precipitation = 4 10-25 <br /> -Site Wells) as o 11umber & Type Irr I om I ub <br /> S Score S Score S Score <br /> istance to Wells) from Tank ft; _ft; ft - C 10 pts C 9 PIS C 5 pts <br /> '0 if 0 if 0 'f` <br /> R conditi on R condition R ordition <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) xxxxxx <10 A 10.25 xxxxxxx 26-40\2 <br /> nn-Made conduits which increase vertical migration <br /> I leachate (i.e., septic systems, water wells, ponds) 0. None Unknown resent <br /> Inique site features: Recharge area, coarse soil, nearby wells. /Z At least lore than <br /> xxxxx None �/? one — one <br /> COLUMN TOTALS»>TOTAL POINTS � t � <br /> ys <br /> ample Result: (B T X OR E) <br /> OLRANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or less <br /> � at K� <br /> I� .00<vi <br /> B T % E R T % E <br /> O(PF MAXIMUM ALLOWABLE B-T•X•E LEVELS (PPM) 1 50 50 50 .3 .3 J. <br /> 1. NA\3 <br /> -ample Result: ASOLINE 1000 100 10 <br /> (�ak 1O3r 1., TPH AXIMUI4 ALLOWABLE TPH LEVELS (PPM) 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 /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth c5 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 /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1• Are BTX & E or TPH Concentrations > Allowable Levels Yes I IN01 <br /> x' <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> V11, 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 r <br /> :VALUATOR 7— r <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />