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SAN JOAOU )LINTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL TH DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> !NAME OF FACILITY G � (SWEEPS CODE I <br /> IADDRESSI I C TANK ID 91, 8 -+I -+(TANK SIZES 0(�U ( FUEL TYPE ' / �7 i '►cv <br /> II. GENERAL SITE HISTORY <br /> Is permit current?(YesNI ( <br /> 0Permit ( Facility Status Code' IOoc.Soil/GW Cont Yes No <br /> Number of Tanks at facility) !Age of Tanks(if available) f ype of Tank Steed IFbrgll Sngll Dual <br /> T <br /> III. TANK HISTORY i N 5 f <br /> Was Tank tested?(YesNo Fail precision test ? Yes No �if yes, give date(s) <br /> Was a repair made to the tank system? Yesl Na If yes, what was repaired?i <br /> I <br /> 'Was repair done under inspection? Yes No) Were soil samples analyzed?IYesj INo, BTXEI ITPH-Gi TPH-Di Pb/EDB( <br /> (Type of failure/discharge catastrophic long-term leakage! overfill) unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> !Soil Samples Received Yes Nol Depth to Ground WaterlRef/Year i,? Average Annual Precipitation A=114 10-25 <br /> ;On-site Well(S) Yes X No !Number & Type Irr )Dom{ IPubl <br /> S Score S Score S Score <br /> ;Distance to WeIL(s) from Tank —L—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 is met E is met I E is met <br /> :Minimum Depth to groundwater from the Soil Sample (feet))._ i >100 ;51-100 I 125-50\1 <br /> 'Fractures in subsurface (applies to foothills or mountain areas) , None I Unknown i Present <br /> (Average Annual Precipitation (inches) �xxxxxx 00 9 10-25 ixxxxxxxi 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) None I Unknown I (Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. I At least) More than <br /> xxxxxx None onel one <br /> COLUMN TOTALS>>TOTAL POINTS <br /> ;Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts I 40 pts or less <br /> i BT X E B I T X E <br /> ! MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 11 50I 50 50 ! .3 I.3 11.I 1. ' NA\3 <br /> (Sample Result: GASOLINE 1000 I 100 I 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH DIESEL 10,000 1000 100 <br /> ,FOOTNOTES: ***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 /> j \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 /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> i <br /> j 1. Are BTX & E or TPH Concentrations > Allowable Levels I*Yes No <br /> i <br /> 2. Recommend Site Closure Yes I No *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 YES( iNOI (REFERRED TO SITE MITIGATION FOR EVALUATIONjYES NOS <br /> DATE REFERRED! / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 30 (UGTWKSHT)\5/90 <br />