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SAN JOAOUIIINTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL *H DIVISION <br /> I. <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> MANKSIZ:El� <br /> TY <br /> L_1a I11`=Y > SO ' �,(;1IZ�. WEEPS CODE <br /> L <br /> 5 55 CSS t �� S'i. ANK ID p <br /> 5 � UEL TYPE1 11 GS / <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? es o ermit q - acidity Status Code oc.Soil/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tank teal Fbrgl ngl Dual <br /> 111. TANK HISTORY <br /> as Tank tested7 as o ailed precision test 7 es o If yes, give date(s) <br /> as a repair made to he tank system? es No f yes, what was repaired? <br /> as repair done under inspection7 as o ere soil snip les analyzed? es o 3TNE I PH-G PH-O b/EDB <br /> ype of failure/discharge otastroph is long-term leakage verf ill nknoun ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Sell Samples Received as ., 0 epth to Ground Water of/Year (4 ; i; U verage Annual Precipitation 4 0-25 <br /> -Site Wells) es o umber 8 Type Irr an ub <br /> S core S core S core <br /> Distance to Well(s) from Tank ft; ft; ft C O. pts C pts C - pts <br /> 0 f 0 f 0 if <br /> A "o diti on R ondition R ondition <br /> Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimun Depth to groundwater from the Soil Sample (feet) rti""q - q >100 -1-100 C 25-5011 <br /> ractures in subsurface (applies to foothills or mountain areas) i �� None Unknown resent <br /> verage Annual Precipitation (inches) xxxxxx <10 9 10-25 Kxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> pique site features: Recharge area, coarse soil, nearby wells. At Least ore than <br /> xxxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more41 4D pts 40 pts or less <br /> .� B T % E B T X E <br /> /Y 1' (4-1 • �� MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NAI <br /> ample Result: GASOLINE 1000 100 tg <br /> AXIMUM ALLOWABLE TPN LEVELS (PPM) <br /> TPH DIESEL 10,000 1000 100 <br /> FOOTNOTES: <br /> ---If documented soil and/or ground water contamination is present, do not caiplete the leaching potential <br /> analysis. (i.e., site Is currently on UGT Contamination List for soil or groud water.) <br /> Ll If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> L If precipitation is > 40 inches, score 0 points. <br /> 13 Levels for BTXBE are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are 8TX 8 E or TPM Concentrations > Allowable Levels Yes IN <br /> o 1- ' <br /> I2. Recommend Site ClosureYes I�`_ �(o I plf Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES I L+01 <br /> EFERRED TO SITE MITIGATION FOR EVALUATION FS I 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF 1Z <br /> VALUATOR /) <br /> EH 23 80 (UGTWKSHT)\5/90 <br />