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SAN JOAOIr�GOUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL`,d-TH DIVISION <br /> I' UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> gANKSIZE <br /> CILITY �� nn 795 WEEPS CODE <br /> I 73 -S C !J / r <br /> UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> M <br /> current? es o ermit # acility Status Code oc.Soil/GW Cont es Jo <br /> Tanks at facility ge of Tanks(if available) ype of Tank teel Fbrgl ngl Dual <br /> III. TANK HISTORY <br /> 'as Tank tested? If <br /> es o IFailed precision test ? 1Y <br /> es o If yes, give date(s) <br /> as a repair made to the tank system? es No 11f yes, what was repaired? <br /> 'ns repair done under inspection? es o ere soil samples analyzed? es to TXE PH-G PH-D b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfill nknown ther: <br /> 1V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> ,oil Samples Received es I IN01 epth to Ground Water Lso of/Year verage Annual Precipitation = 4 10-25 <br /> n-Site Welts) es o umber & Type Irr om ub <br /> S Score S Score 5 3core <br /> istance to Welt(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 f <br /> R ondition R condition R ondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E s met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100FV" 4Q <br /> 5 25 50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) 1 o None Unknown resent <br /> verage Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> nn-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> lnique site features: Recharge area, coarse soil, nearby wells. At Least ore than <br /> �xxxxx None q one one <br /> COLUMN TOTALS>>>TOTAL POINTS U + 7 <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 XE B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PFM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> 'ample Result: GASOLINE 1000 100 10 <br /> AXIMUM 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 /> \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&c' 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 Jo <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/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE "ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION YES d0 <br /> :ATE REFERRED DATE CLOSURE LETTER MAILED <br /> AME OF <br /> :VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />