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SAN JOAOUIk COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> I• UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> E OF fACIL1TY �� �.� ��S IS <br /> WEEPS CODE <br /> rAWK <br /> RESS OCP E-- ���j ANK ID # <br /> SIZE 1 .SG pE UEL TYPE <br /> It. GENERAL SITE HISTORY <br /> ** <br /> Is permit current? es I 4o I ermit # lFaciLity Status Code oc.Soil/GW t es _ o <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tank teel rgl Dual <br /> 111. TANK HISTORY <br /> Jas Tank tested? es o Vfaited precision test ? es I Igol If yes, give date(s) / <br /> Jas a repair made to the tank system? Yes No I V11f yes, what was repaired? <br /> Jas repair done under inspection? es go ere soil samples anatyzed7 es o TXE PH-G PH-0 b/EDB <br /> ype of failure/dischargeatastrophic long-term leakage overfill nown other: <br /> je- <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es I Igol epth to Ground Water of/Year verage Annual Precipitation = 4 0-25 <br /> -Site Wells) es o umber & Type 11r om ub <br /> S Score S Score S Score <br /> istance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C5 pts <br /> 0 if 0 if 0 if <br /> R condition R condition R ondition <br /> Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 25-50,L <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown PIresent <br /> verage Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-402 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> pique site features: Recharge area, coarse soil, nearby wells. At least 4ore than <br /> xxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS + 3 v + <br /> Sample R e�ul't: E T X OR�OK RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> Z1�pV� ' 8 T X E B IT X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 150 <br /> 50 ,3 .3 1. 1. NAl <br /> Sample Result: SOLINE 1000 100 10 <br /> IMUM ALLOWABLE TPH LEVELS (PPM) <br /> � TPN rlESEL 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 /> 12 If precipitation is > 40 inches, score 0 points. <br /> L 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 /> Z-dY.J : <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure es oIf 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 fES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES O <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EM 23 80 (UGTWKSHT)\5/90 <br />