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a <br /> SAN JOAOUI$19NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL WTH DIVISION <br /> E. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY .i SWEEPS CODE <br /> DDRESS v mTANK ID # <br /> TANK SIZE UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> +r <br /> Is permit current? es o ermit # acility Status Code oc. /GW Cont cs o <br /> umber of Tanks at facility kqe of Tanks(if available) ype of Tankteel Fbrgt ISN11 Dual <br /> i11. TANK HISTORY <br /> as Tank tested? es o ailed precision test ? eso If yes, give dates) <br /> as a repair made to the tank system? es No f yes, what was repaired?. ; PD as repair done under inspection? es o ere soil samples analyzed? es to TXE PH � P-G V_ H-D D <br /> ype of failue/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 /> Soft Samples Received es �( o epth to Ground Water ' of/Year ( (( verage Annual Precipitation 4 10 25 <br /> n-Site Wells) es o1. umber & Type Irr om ___F <br /> S Score. S Score 5 3core <br /> istance to Wett(s) from Tank ft; _f t; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 fif <br /> V. <br /> R ondition R ondition R ondltion <br /> Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Sail Sample (feet) >100 1-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown ;resent <br /> Verage Annual Precipitation (inches) xxxxx -10 9 10-25 xxxxxxx 25-4012 <br /> an-Made conduits which increase vertical migration ,--- <br /> f leachate (i.e., septic systems; water wetts, ponds) None Unknown Pfesent <br /> Inique site features: Recharge area, coarse soil, nearby wells: At least lore than <br /> XXXXx None one one <br /> COLUMN..TOTALS»>TOTAL POINTS ,V + 7 (�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 I X E 8 T X E <br /> MAXIMUM ALLOWABLE ti-T-X•E LEVELS (PPM) 1 50 50 50 3 3 1. 1. NA\3 <br /> Sample Result: GASOLINE 1000 10 10 <br /> 7q AXIMUM ALLOWABLE TPH LEVELS.(PPM) <br /> yn TPH _ IESEL 10,000 1000 100 <br /> OOTNOTES: ***If documented soil end/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 paints. <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 =r <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure 1Yes o '� If Yes, Refer to Site Mitigation for Evaluation <br /> V11. REVIEW EVALUATION - TO BE C014PLETED BY A SUPERVISOR/SE)410R II <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EF.ERRED TO SITE MITIGATION FOR EVALUATION ES O .i <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> :VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />