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r <br /> SAN JOAU,,.,COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL`,.LTH DIVISION <br /> I• UGST WORKSHEET FOR SITE CLOSURE EVALUATIONATE a �? <br /> AME OF FACILITY LASWEEPS CODE <br /> DRESS l''00 TANK ID # - <br /> ANK SIZE IFUELTYPE <br /> II. GENERAL SITE HISTORY <br /> ** <br /> Is permit current? es o ermit # - acility Status Code F oc.Soil/GW Cont IYes o <br /> umber of Tanks at facility kge of Tanks(if available) ype of Tank feel Fbrglngl I Dual <br /> 1I1. TANK HISTORY <br /> Jas Tank tested? es o ailed precision test ? es N0If yes, give dates) <br /> as a repair made to the tank system? 1Yes No f yes, what was repaired? <br /> as repair done under inspection? es I No ere soil samples analyzed? es o TXE PH-G PH-D b/EDB <br /> ype of failure/discharge atastrophic tong-term leakage verfill nknown 1 10ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received 1Yes o epth to Ground Water of/Year 14verage Annual Precipitation <br /> -Site Well(S) es o umber & Type Irr om ub <br /> S Score S Score S core <br /> istance to Welt(s) from Tank ft; ft; ft C 10 pts C 9 pts C 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) ( ^a , >100 1-100 25-5011 <br /> Fractures in subsurface (applies to foothills or mountain areas) 1 D None Unknown DIresent <br /> Average Annual Precipitation (inches) xxxxx <10 9 10-25 xxxxxxx 26-4012 <br /> Ian-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown j resent <br /> nique site features: Recharge area, coarse soil, nearby wells. At least ore than <br /> xxxxx None q one ? Come <br /> COLUMN TOTALS»>TOTAL POINTS + / + J / <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 XTEMAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 5 .3 .3 1. 1. NA13 <br /> Sample Result: ASOLINE 1000 100 10 <br /> �n/J /n� FAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> /x�LJ TPH fESEL 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 /> Z If precipitation is > 40 inches, score 0 points. <br /> 13 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 /> JC C sc �74�- <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes 11 <br /> o 0 C-J L <br /> 2. Recommend Site Closure es o if Yes, Refer to Site Mitigation for Evaluation s: _"p��i� T- <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR J <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE fES1 0 EFERRED TO SITE MITIGATION FOR EVALUATION YES I INO <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AMEOF <br /> VALUATOR c <br /> EH 23 80 (UGTWKSHT)\5/90 <br />