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SAN JOAw•COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL LTH DIVISION <br /> 1' UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY /? WEEPS CODE ca / <br /> DRESS 2q <br /> ANK 1-0 # J / � '✓` '--• Q <br /> ANK SIZE I a UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> ww <br /> Is permit current? as o ermit # - acility Status Code 1 oc.Soil/GW Cont es o <br /> umber of Tanks at facility Be of Tanks(if available) 8' ype of Tank teal 1, Fbrgl ngl Dual <br /> 111. TANK HISTORY <br /> jYpef <br /> ested? as o ailed precisi4mtest 7 es o If yes, give date(s) <br /> ir made to the tank system? es f yes, what was repaired? <br /> done under inspection? es ore soil samrp les analyzed? es o <br /> Tr; PH-G PH-D b/EDB <br /> ilure/discharge atastrophiclong-term leakage verfill nknown ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received as 0 epth to Ground Water 5() of/Year ��; verage Annual Precipitation = 4 0-25 <br /> n-Site Well(s) as o umber 8 Type 11" I k.1ub <br /> istance to Wetl(s) from Tank ft; ft; f[ 5 core S core S core <br /> C 0 pts C 9 pts C pts <br /> 0 if 0 if 0 if <br /> R ondition R condition R ondition <br /> Site Feature - Leaching Poten41e <br /> lysis E is met E is met E is met <br /> inimum Depth to groundwater froml Sample (feet) . I rj -100 1-100 25-SO,L1 <br /> ractures in subsurface (applies tills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inchxxxxx <10 9 10-25 mxxxx 26-4OL2 <br /> an-Made conduits which increase vmigration <br /> f leachate (i.e., septic systems, wells, ponds) C' None Unknown resent <br /> nique site features: Recharge aarse soil, nearby wells. At least ore than <br /> xxxxx None one one <br /> COLUMN TOTALAL POINTS �ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> B T X E 8 T % EMALOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA1 <br /> ample Result: ASOLINE 1000 ipp 10 <br /> 3 •_ j AXIMUM ALLOWABLE TPN LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> OOTNOTES: ***If documented soil and/or ground water contamination is present, do not cemplete the teaching potential <br /> analysis. (i.e., site is currently on UGT Coltamina tion List for soil or ground water.) <br /> L If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> )2 If prec ipitati of is > 40 inches, score 0 points. <br /> 1 Levels for BTXSE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION Qe C to •T� .ca Ila V1 �/ <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o \ -FftNr,S d- #3 /. <br /> PAP.(-- .chi <br /> 2. Recommend Site Closure as oIf Yes, Refer to Site Mitigatim for Evaluation <br /> pIn <br /> VII. REVIEW EVALUATION - TO 8E COMPLETED BY A SUPERVISOR/SENIOR u4,6P W Cm d4Z <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 1001 <br /> ATE REFERRED / � / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> -VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />