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SAN JOAO11000UNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY SWEEPS CODE <br /> DDRESS I TANK ID # <br /> TANK SIZE IF UEL TYPE <br /> Ii. GENERAL SITE HISTORY <br /> Is permit current? es o ermit # acility Status CodeI ID oc.Soi(/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) IType of Tank ISteel Fbrgl ngl Dual <br /> III. TANK HISTORY <br /> as Tank tested? es I IN01 ailed precision test ? es o If yes, give date(s) <br /> as a repair made to the tank system? Yes No 11f yes, what was repaired? <br /> as repair done under inspection? F <br /> oEtongte <br /> soil samples analyzed? es Jo TXE PH-G PH- <br /> ypeIT <br /> of failure/discharge atastrophic m leakage verfill nknown Cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received 1Yes I IN01 epth to Ground Water of/Year verage Annual Precipitation = 4 10 25 <br /> n-Site Wells) es 40 Number & Type Irr om ub <br /> S score S Score S Score <br /> istance to Wells) from Tank 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 /> Site Feature - Leaching Potential Analysis r— Z 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 /> ractures in subsurface (applies to foothills or mountain areas) None Unknown41 resent <br /> verage Annual Precipitation (inches) x <10 �� 10-25 xxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> Df leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> Inique site features: Recharge area, coarse soil, nearby wells. n At least 'lore than <br /> xx None f one / one <br /> COLUMN TOTALS»>TOTAL POINTS14 I TV M-111 -+ + -1�r <br /> I <br /> 'ample Result: (B T X OR E) RANGE OF TOTAL POINTS ,9 pts or more 48 pts 40 pts or less <br /> B I T X E B T X E <br /> MAXIMUM ALLOWABLE B T X E LEVELS (PPM) 1 50 50 5 .3 .3 1. 1. NA\3 <br /> "ample Result: ASOLTNE 1000 100 10 <br /> AXIMUM ALLOWABLE TPN LEVELS (PPM) <br /> TPH IIEIEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, not complet he leaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List 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&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 I IN01 <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 /> .ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES I INOI <br /> EFERRED TO SITE MITIGATION FOR EVALUATION YES JO <br /> )ATE REFERRED I / ATE CLOSURE LETTER MAILED <br /> dAME OF <br /> :VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />