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SAN JOAOU, BOUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL r._.,_iH DIVISION <br /> 1. UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE C`l C <br /> AME OF FACILITY �� U- ECORD ID <br /> ADDRESS ( � �,1 ANK ID # jq l/ S�,` C , <br /> I �. C;C C= <br /> TANK SIZE rC, �C� UEL TYPE ? <br /> 11. GENERAL SITE HISTORY <br /> �` yrr <br /> Is permit current? es o ermit # acility Status Code 1 oc.Soil/GN Cont es o <br /> Number of Tanks at facility ge of Tank(if availab(e) � ype of Tank teel Fbrgl ngl Dual <br /> III. TANK HISTORY <br /> as Tank tested? If <br /> as o ailed precision test ? es o If yes, give date(s) <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> as repair done under inspection? eso ere soil samples analyzed? es o TXE PH-G PH-D b/EDB <br /> Type of failure/discharge atastrophic long-term leakage verfill nknown they: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Receivedes o <br /> esIf I <br /> epth to Ground Water of/Year �C �- verage Annual Precipitation <br /> n-Site Well(S) o umber & Type Irr I om ub <br /> S Score S Score S 3core <br /> Distance to Well(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 ondition <br /> Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) . None Unknown Dresent <br /> verage Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40N2 <br /> Ian-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) None Unknown Dresent <br /> pique site features: Recharge area, coarse soil, or wells. C At least ore than <br /> lMuncipal=>2000 ft; domestic=>500 ft; irr/agricultural=present] xxxxxx None 7 one one <br /> COLUMN TOTALS»>TOTAL POINTS ! + + I v Lj <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or less <br /> / _ B T X E B JT X E <br /> ��3 1-44G MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NAL <br /> ample Result•_ ASOLINE 1000 100 - 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> (8(.iC) 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 /> 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 /> \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 /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes ( o <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED /- i_ / - ATE CLOSURE LETTER MAILED <br /> AME OF <br /> EH 23 30 (UGTWKSHT)\5/94 <br />