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SAN JOA01 iTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL ,. DIVISION <br /> I I , L UGST WORKSHEET FOR SITE CLOSURE EVALUATION ra <br /> TE 1 --� — C, L <br /> NAME OF FACILITY �.U.� �� - tJ _ Sa\jo SWEEPS CODE I G <br /> ADDRESS 1C{ QI S• Cid 7t7l�GlL�,O TANK ID # OI <br /> TANK SIZE 1*000 CL FUEL TYPE a%1tna jOQZ - OZ <br /> ( 1042- 03 <br /> II . GENERAL S TE OST SP <br /> Its permit current? Yes No Permit # - foci li cy Status Cade Doc-Soil /GW Cont Yes No <br /> . Number of Tanks at facility Age of Tanks ( if available) Type of Tan Stee Fbrgl ngl Dual <br /> [ ( I . TANK HISTORY <br /> was Tank tested? Yes No Failed precision test ? Yes No If yes , give date( s ) <br /> Was a repair made to the tank system? Yes No If yes , What Was repaired? <br /> , Was repair done under inspection? Yes No Were soil samples analyzed? ; Yes No BTXE ITPH-G TPH-D Pb/EDB <br /> 'voe of failure/discharge catastrophic long- term leakage overfiLl unknown other : <br /> i <br /> 'v . REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT ]ATA FOR LEACHING POTENTIAL ANALYSIS) <br /> ; Soil Samples Received es No Depth to Ground Water Ref/Year I Q3; 1 (,I� Average Annual Precipitation A= 14 10- 25 <br /> � On- Site WeLI ( S ) Yes No Number 8 Type Irr Dam Pub <br /> i S Score S Score S Score <br /> i ; Distance to WeLL ( s ) from Tank ft ; ft ; ft C 10 pts C 9 pts C 5 pts <br /> a if 0 if 0 if <br /> E R condition R condition R condition <br /> : V . Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> . Minimum Depth to groundwater from the Soil Sample ( feet ) TOT I > 100 51 - 100 25 -50\1 <br /> ractures in subsurface ( applies to foothiLLs or mountain areas ) Its None Unknown Present <br /> ' Average Annual Precipitation ( inches ) xxxxxx <10 9 10- 25 xxxmm 26- 40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate ( i . e . , septic systems , water welts , ponds ) to None Unknown Present <br /> i <br /> ' Unique site features : Recharge area , coarse soil , nearby wells . At Least More than <br /> xxxxxx None one one <br />( P�IYM nC' V1L Ioa--pftbn � E} �Dy� iyl1171f1Ltrlpl1 q <br /> I' ��Ct � tG (itnidLvnt l fla �^an-UMN TO ALS»>Yb'f'AL • POINTS 2� + q ; — = Z9 <br /> t <br /> . SampLe Result : ( B T X OR E ) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or Less <br /> B -o.ob5opm 1( �; p 20 pp <br /> iT 5 .5 IGpprv1 E"2 A3pp�rvl MAXIMUM ALLOWABLE B- T- X- E LEVELS ( PPM) 6 50 50 50 . 3 .3 X . 1 . NA\3 <br /> t ( Sample Result : GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> i <br /> 3TPH DIESEL 100000 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&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 No <br /> 2 . Recommend Site Closure Yes No If Yes , Refer to Site Mitigation for Evaluation <br /> i <br /> Vit . REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> i NAME OF <br /> i. EVALUATOR <br /> i <br /> j_ EH 23 80 (UGTWKSHT )\5/90 <br />