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SAN JOAO COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION p <br /> I' UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY CJ. �/D�i WEEPS CODE <br /> �// <br /> DRESS �Oti D (D C � / _ _ - ANK W,# <br /> ANK SIZE OQO UEL TYPE � �— <br /> 11. GENERAL SITE HISTORY <br /> ♦� <br /> Is permit current? es 0 ermit q acility Status Code oc.Soi L/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tank Leel FbrgL ngl Dual <br /> 111. TANK HISTORY <br /> as Tank tested? es o ailed precision test ? es o If yes, give date(s) (l� j /0 <br /> as a repair made to the tank system? es No f yes, what was repaired? '.1 i7,� �gb < ,n.X LzgcLC,G.'.rc�l'✓�C�! _z <br /> as repair done under inspection? as o ere soil samples analyzed? e o TXE PH-G PH-D b/EDB <br /> Type of failure/discharge atastrophic Iong-term leakage verfiLL nknown they: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Suit Samples Received es o epth to Ground Water of/Year Q(2 verage Annual Precipitation = 4 0-25 <br /> -Site Wells) es o umber 8 Type Irr an ub <br /> S Score S core <br /> istance to WetL(s) from Tank ft; ft; ft C 0 pts C pts C pts <br /> 0 t o if 0 f <br /> R conditi onV. R ondition <br /> Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sanple (feet) >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 xmxmx 26-401 <br /> Ian-Made conduits which increase vertical migration <br /> f leachate e., septic systems, water wells, ponds) None Unknown resent <br /> nique site features: Recharge area, coarse soil, nearby wells. At least ore than <br /> xxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS ♦ t <br /> amUpleRe. sult: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or Less <br /> 00 <br /> �Ihb7 o f x M(' c o J�Gw 8 T X E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA1 <br /> ample ResuLt: ASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPN LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> OOTNOTE S: ---if documented soil and/or ground water contamination Is present, do not canplete the leaching potential <br /> analysis. (i.e., site is currently on UGT Contmnination 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 /> L If precipitation is > 40 inches, score 0 points. <br /> L Levels for BTXBE are not appLicabLe at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> It2CC/5p— r�" � Got ,jv FYbu/ <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o l- aSLZ� -7i q,L� <br /> 2. Recommend Site Closure Yes I o I �If Yes, Refer to Site Mitigation for Evaluation <br /> V11. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR 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 <br /> EH 23 80 (UGTWKSHT)\5/90 <br />