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SAN JOAOU•COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTA0L HEALTH DIVISION <br /> I• UGST WORKSHEET FOR SITE CLOSURE EVALUATION AIE <br /> AME OF FACILITY D� WEE PS CODE 7j <br /> DRESS Q �—, {�J / �n <br /> AHKI-0 p <br /> ANK SIZE UEL TYPE <br /> 11. GENERAL SITE HISTORY V <br /> Is permit current? es o ermit 0acility Status Code 9 oc.Soi l/GW C tes o <br /> umber of tanks at facility ge of Tanks(if available) ype of Tank teel FbrgL rgl Duel <br /> III. TANK HISTORY <br /> as Tank tested? es I VIHO ailed precision test as L L11 o If yes, give date(s) 8'/ <br /> Jas a repair made to the tank system? as No f yes, what was repaired? <br /> as repair done under inspection? es qo ere soil samples analyzedT es o TKE PH-G PH-D b/EDB <br /> Type of failure/discharge atastrophic long-term leakage verf ill nknown cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es o I epth to Ground Water ) of/Year, ; verage Amual Precipitation = 4 0-25 <br /> n-Site Wells) as o umber 8 Type Irr an ub <br /> S Score S Score S core <br /> istance to Wells) from Tenk ft; ft; ft C 10 pts C 9 pts C pts <br /> 0 if 0 if 0 if <br /> R ondition R condition R ondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E s met <br /> inimum Depth to groundwater from the Soil Sample (feet)s0 f. >100 1-100 25-50L <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxx 26.401 <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 /> xmx None one one <br /> COLUMN TOTALS>»TOTAL POINTS + + <br /> ampte Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> B T K E B T K E <br /> =' �✓ + MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NAL <br /> Sample Result: ASOLINE 1000 100 10 <br /> u. TAX <br /> IMUM 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 complete the leaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> ,L1 If depth is > 5 ft, and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> 1 If precipitation is > 40 inches, score 0 points. <br /> L3 Levels for BTKBE are not appticable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION .r _ A,. _ rt �- <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure IYes o If 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 0 I FERRED TO SITE MITIGATION FOR EVALUATION ES I 0 <br /> ATE REFERRED I ATE CLOSURE LETTER MAILED I <br /> AME OF <br /> _VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />