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• ' i <br /> SAN JOAOU344NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HsH DIVISIONp <br /> 1. UGST WORKSHEET FOA SITE CLOSURE EVALUATION ATE �•�8, Z <br /> AME OF FACILITYpd� , e I <br /> WEEPS CODE <br /> ADRESS O pq O O 5 G ft ANK ID # <br /> ANK SIZE UEL TYPE jr `4' �p00 <br /> I1. GENERAL SITE HISTORY a ,llD 0 9 a� <br /> ** 111 <br /> Is permit current? es o I_tlefrmit # acitity Status Code ,,.Soil/GW Cont IYCS o <br /> umber of Tanks at facility S ge of Tanks(if avail abte) ..-type of Tank teel I Fbrgl I ngl I Dual <br /> 111. TANK HISTORY 4riSF I LA I`t(0 dn�CllGu}y� <br /> as Tank tested? es o ailed precision test ? es a If yes, give dates) <br /> as a repair made to the tank System? es No f yes, what was repaired? <br /> r+s repair done under inspection? Ifes o Jere soil samples analyzed? IYesl Jo I TXE PH-G' PH-D I b/EDB <br /> ype of failure/discharge atastr,phic Long-term leakageverfiLt nknown ther: <br /> 1V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) i <br /> oil Sample§�'Received es o epth to Ground Water 7�D of/Year verage A meal Precipitation = 4 10 25 1111 <br /> in-site Well(s) es 'o umber & Type 11 rr I om I ub <br /> S core 5 Score 5 icorm <br /> istance to Welts) from Tank ft; ft; oft C 10 pts C 9 pts C i pts <br /> 0 if 0 if 0 if <br /> v. <br /> R ondition R ondition R ondition <br /> Site Feature - Leaching Potential Analysis E is met f is met E s met <br /> inimum Depth to groundwater from the-Soil;Sample (feet):3p-j5_, j5' >100 1-100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) O None Unknown resent <br /> verage Annual Precipitation (inches) xxxxxx <10. 9 10-25 xxxxxx 26-40\2 <br /> nn-Made conduits which increase vertical migration <br /> f Leachate (i.e., Septic systems, water wells, ponds). None 9 Unknown Dresent <br /> lnfque site features: Recharge area, coarse soil, nearby welts.' At least lore than <br /> xxxxx None- one one i <br /> COLUMN.TOTALS>>>TOTAL POINTS 2 i O , <br /> a le Result: (B T X OR E) RANGE OF TOTAL POINTS ,9 pts or more 41 - ,48 pts 40 pts or less <br /> B- .it +►7 �PJh <br /> B T X E B T X E' <br /> 19 P Fr1MAXIMUM ALLOWABLE B-T•X-£ LEVELS- (P ) 1 50 50 50 3 3 1: 1. NA\3 <br /> Sample Result: ASOO NE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS,(PPM) <br /> 31COOMmTPH-�qr IESEL, 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 groundwater.) <br /> \1 If depth is > 5 ft. and c 25 ft., score 0 points:. If depth <=5 ft., do'not use table. A <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 RECOMMENDAT]ON/CRHCLUSION MC) l h„JL4-d CUld/ <br /> 1, Are BTX & E or TPH Concentrations > Allowable Levels Yes o N T� ✓�y} ,}-- <br /> 2. Recomnend Site Closure 1Yes o 1 If Yes, Refer to Site Mitigation for Evaluation <br /> vfl. REVIEW EVALUATION --TO BE CCMPLETED BY A'SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR-CL65URE YES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / 9v ATE CLOSURE LETTER MAILED <br /> i <br /> AME OF <br /> -VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 - <br />