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SAN JOAOl1IA`„/JNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL K"'rH DIVISION <br /> I• UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE Z <br /> AME OF FACILITY J � OP sSWEEPS CODE <br /> DDRESS 6 Olrl TANK ID <br /> TANK SIZE UEL TYPE �-O G <br /> 11. GENERAL SITE MTORY <br /> Is permit current? es o ermit # acility Status Code oc.Soil/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tank feel Fbrgl ngl Dual <br /> III. TANK HISTORY <br /> as Tank tested? es o ailed precision test ? es o If yes, give date(S) <br /> Jas a repair made to the tank system? as No 11f yes, what was repaired? <br /> ns repair done under inspection? eso ere soil samples analyzed? es to TXE PH-G PH-D b/EDB <br /> ype of failure/discharge atastrophic long-term tea IDverfitt nknown 1 10ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Receivedes �( o epth to Ground Water Lld of/Year �6, verage Annual Precipitation = 4 10-25 <br /> Site Wells) es o umber & Type Irr om t ub <br /> S Score S Score S Score <br /> istance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R condition R condition R condition <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) "l >100 1-100 $ 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) /0 None Unknown >resent <br /> verage Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> Inique site features: Recharge area, coarse soil, nearby wells: At least lore than <br /> xxxxx None r one once <br /> COLUMN TOTALS>>>TOTAL POINTS 17a * ( + /0 <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> X N Ddk�z PP"' p a�" <br /> tj B B T X E B X EMAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1505050 .3 J.T <br /> 3 1. 1. NA\3 <br /> 'ample Re lt: D1�pP ASOLINE 1000 100 10 <br /> N AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TP i� 1 M IESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the Leac i en ial <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 <=5 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 /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure 1Yes I 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 fES I IND EFERRED TO SITE MITIGATION FOR EVALUATION fES JO <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> :VALUATORJ " <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />