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J <br /> SAN JOACXJ14^`C'OUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL h_�v�H DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE /J y <br /> AME OF FACILITY yy, l� WEEPS CODE 9d <br /> DDRESS �� ��7 J �' zoo//- �1�JTANK 1D # 3 — <br /> TANK 3 D <br /> SIZE �-�b UEL TYPE vlar. <br /> It. GENERAL SITE HISTORY <br /> ** <br /> Is permit current? es 0 N/ ermit # acility Status Code oc.SoiL/GW Cont es DE <br /> umber of Tanks at facility rnI,��13 ge of Tanks(if available) ype of Tank reel FbrgI ngl Dual <br /> 111. TANK HISTORY <br /> as Tank tested? es o I ailed precision test ? es o If yes, give date(S) <br /> as a repair made to the tank system? Yes No f yes, what was repaired? <br /> ns repair done under inspection? es 40 dere soil samples analyzed? 1Yes I Jo TXE I PH-G I IT <br /> PH-D b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfill nknown ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received esN o epth to Ground Water130 <br /> of/Year verage Annual Precipitation = 4 10-25 <br /> Site Welt(s) IYes 0 umber & Type Irr om ub <br /> S core S Score S Score <br /> istance to Welt(s) from Tank ft; _f t; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R ondition R condition R ondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet)P-3&= f© >100 1-100 ul 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) 10 None Unknown resent <br /> verage Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) None Unknown Dresent <br /> lnique site features: Recharge area, coarse soil, nearby wells. f At least 4ore than <br /> xxxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS + t + <br /> awn le Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> I •pis 6 •h <br /> 3 .0q7_ X •6 1 B T X E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> 'ample Result: ASOLINE 1000 100 10 <br /> /, AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> �• � TPN lESEL 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 /> \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 /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes IN <br /> o <br /> 2. Recommend Site Closure 1Yes o IX If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION fES F77 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> .VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />