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« ={ SAN JOAOUINTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL Q411 DIVISION <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION A7E 0 Z3 GJ <br /> pF FACILITY av—� �...-,.a -�r � )SWEEPS CODE <br /> DRESS f�� , ! M i! ANK !D *, '� ' HOZ �QZ <br /> AHK SIZE IJEL TYPE <br /> it. GENERAL SITE HISTORY <br /> i . <br /> F * <br /> Es permit current? eso ermit alf - aci(ity Status Code oc.SoiL/GW Cant es o <br /> p <br /> Luber of Tanks at facility ge of Tank (if available) Ff Tank Leel jjbrgt ngl I Dual <br /> 111. TANK HISTORY <br /> Jas Tank tested? Ifes Ool ailed precision test ? es o [f yes, give date(s) <br /> 4 as a repair made to the tank system? Yes No f yes, what was repaired?ft � <br /> os repair done r inspection? es o ere son[ samples analyzed? as o TXI: PN-G PH-D b/EDB <br /> ype of failure/ scharge atastrophic long-term leakage verfilt mown then: <br /> 1V. REMOVAL HISTORY (ATTACH INS ECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received as epth to Ground Water I of/Year 1: erage Annual Precipitation 4 0-25 <br /> 4111 <br /> j -Site WeEI(s) es o umber & Type Irr om <br /> S score S Score S Score <br /> istance to Well(s) from Tank ft; _f t; _f t C 10 pts; C pis C 5 pts <br /> 0 if p 0 if 0 if <br /> R rondition R condition R ondition <br /> f. Site Feature - Leaching Potential Analysis !�v(�MP/%,6/ E is metl� E is met E is met <br /> inimum Depth to groundwater from the Soil Sample ( $ IPI >100 i� 1-104 25-50L <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) xxxxxx 410 ; 9 10-25 xxxxxxx 26-40L <br /> an-Made conduits which increase vertical migration a <br /> f leachate (i.e., septic systems, water wells, ponds) None 'h ! Unknown resent <br /> ique site features: Recharge area, coarse'soil, nearby wells. (} At least 4ore than <br /> KX <br /> xxxx None Jfr one one <br /> COLUMN TOTALS»>TOTAL POINTS • '� l(/ D <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 ptsy�or mare 41 - 48 pts 40 pts or Less <br /> 8 T X E� B JT X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50' 50 SO .3 .3 1. 1. NA�3 <br /> ample Result: SOLINE 1000 k 100 10 <br /> IMAM ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 10;000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present,�do not complete the leaching potentisE <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> 11 If depth is > 5 ft. and < 25 ft., score O points. if depth 4=5 ft., do not use table. <br /> L2 if precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTX&E are not applicabLe at a TPH concentration of 101fppn (gasoline) or 100 ppm (diesel). - <br /> VI. STAFF RECOMMENDATION/CONCLUSION ��Qln 0n f'P1Itj ='q�2(�,� ylak. <br /> IL <br /> 1. Are BTX & E or TPH Concentrations > A owable Levels Yes o I all ; {w'� 7S" j �'y /� <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evacuation y� L ap PPM 0 , <br /> VI1. REVIEW EVALUATION - TO BE COMPLETED BY A SU ISOR/SENIOR cE�� S= St700 <br /> -fib Carom I�r'Sm..-�� <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE fES 0 EFERRED TO SETE;jMITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR � E <br /> EH 23 80 (UGTWKSHT)\5/90 Wa T "D <br /> 4 i� , <br />