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SAN JOI .JNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL 'H DIVISION <br /> 1 , r UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE •' �"� . �)` y <br /> AME OF FACILITY lam /�-,� � , ) � "WEEPS CODE <br /> , fir - �; �, r� <br /> �,I ANK ID X <br /> DORESS - ` f � �-�-. �j�s� r,4 -):�. T� <br /> TANK SIZE UEL TYPE <br /> 11 , GENERAL SITE HISTORY <br /> Is permit current ? as o ermit # aciLity Status Code oc . Soil /GW Cant as o <br /> umber of Tanks at facility Be of Tanks ( if available) ype of Tank tee ( Fbrgl ngL Dual <br /> II L TANK HISTORY <br /> Ellis Tank tested? as o ailed precision test ? as o If yes , give date( s ) <br /> as a repair made to the tank system? as No f yes , what was repaired? <br /> Ems repair time under inspection? as No ere soil samples analyzed? as 10 TXE PH • G PH -D 6/ EDB <br /> ype of failure/discharge atastrophic long - term leakage verfitL nknown ther : <br /> iV , REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS ) <br /> oil Samples Received as a epth to Ground Water ZS of/Year L- verage Annual Precipitation <br /> , Site Well ( s ) as o umber & Type irr an uo <br /> S score S Score S core <br /> istance to WeIL ( s ) from Tank ft ; ft ; ft C 10 pts C 9 pts C pts <br /> 0 if 0 if 0 ' f <br /> R condition R conditi on R ondition <br /> Site Feature - Leaching Potential Analysis ( ' �L — 2 j ( 1 . S! E is met E is met E s met <br /> inimum Depth to groundwater from the Soil Sample ( feet) > 100 1 . 100 (y 25150\ 1 <br /> ractures in subsurface ( applies to foothills or mountain areas ) ID None Unknown resent <br /> verage Annual Precipitation ( inches ) XXXXXA <10 9 10- 25 Kxxxxxx 26- 40\2 <br /> nn-Made conduits which increase vertical migration / <br /> ( leachate ( i . e . , septic systems , water wells , ponds ) / D None Unknown resent <br /> )nique site features : Recharge area , coarse soil , nearby wells . At Least lore than <br /> XXXXX None 9 One one <br /> COLUMN TOTALS»>TOTAL POINTS <br /> ample Result : ( B T X OR E ) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or Less <br /> - :- ," JC ISO'Lx/ryvi_ B TX E B T X E <br /> !� 31 . MAXIMUM ALLOWABLE 0 - T • X -E LEVELS ( PPM ) 1 50 50 50 . 3 . 3 1 . 1 . NA\3 <br /> ample Result : ASOLtNEI . 1000 100 10 <br /> AXIMUM ALLOWABLE TPN LEVELS ( PPM ) <br /> 7 rJ 6 o, TPH �' 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 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 STXBE are not applicable at a TPH concentration of 10 porn (gasoline ) or 100 ppm ( diesel ) . <br /> V1 . STAFF RECOMMENDATION/CONCLUSION <br /> 1 , Are RTX 8 E or TPH Concentrations > Allocable Levels Yes 0 <br /> 2 . Recommend Site Closure es o I VIIJIf Yes , Refer to Site Mitigation for Evaluation <br /> %III . REVIEW EVALUATION TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> ,ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF � <br /> .VALUATOR <br /> r <br /> EH 23 80 ( UGTWKSHT ) \5/90 <br /> EH 29 80 <br />