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SAN JOAaV,,,COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTALyALTH DIVISION <br /> I• UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> rAME OF FACILITY k�cw TW9A4 ISWEEPS 4ODEDRESS 5& '5wC�( � ANK ID <br /> ANK SIZE UEL TYPE <br /> I1. GENERAL SITE HISTORY <br /> ** <br /> Is permit current? es o ermit it - acitity Status Code Soil/GW Cont es I o <br /> umber of Tanks at facility kge of Tanks(if available) ype of Tank IS <br /> tee( I Fbrgl ngl I Dual <br /> III. TANK HISTORY <br /> Jas Tank tested? es o I ll ailed precision test ? es o If yes, give dates) <br /> Jas a repair made to the tank system? IYes No 11f yes, what was repaired? <br /> Jas repair done under inspection? es No ere soil samples analyzed? es o J�ATXE PH-G PH-D �ED <br /> ype of failure/discharge I atastrophiclong-term leakage vertill nkn7— ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received as IANO epth to Ground Water f(00 of/Year 3 ; Overage Annual Precipitation <br /> -Site Well(S) es 1,110 1 umber & Type Irr om ub <br /> S Score S Score S core <br /> istance to Wel((S) from Tank 2ft; ft; ft C 10 pts C 9 pts C pts <br /> 0 if 0 if 0 "f <br /> V. Site Feature - Leaching Potential Analysis R ondition R condition R condition a S�pj E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feetyq >100 1-100 S 25-5011 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 KXXXxxx 26-40,2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) ,� None Unknown resent <br /> pique site features: Recharge area, coarse soil, nearby wells. At least 4ore than <br /> xxxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS V + + � <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> ��.MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) B 50 50 50 .3 .3 1. 1. (NA",i3 <br /> n <br /> ample Result: ASOLINE 1000 100 10 f <br />� / � AXIMUM ALLOWABLE TPH LEVELS (PPM) IG <br /> TPH IESEL 1 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 /> 11 If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> ,12 If precipitation is > 40 inches, score 0 points. <br /> L 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 - ,, <br /> 2. Recmm*nd Site Closure es I .f Yes, Refer toSiteMitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED eY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION JES1 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />