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II 4 <br /> 4 I SAN JOAOU' ]UNTY PUBLIC HEALTH SERVICES/ENVIRONMENTALN DIVISION p �] <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATIOATE <br /> AmF OF FACILITY eS EEPS CODE 171S <br /> DDRESS �a } S ANK ID # <br /> [\JJ1 ANK SIZEUEL TYPE <br /> iI. GENERAL SITE NIS RY j <br /> rr ' <br /> Is permit current? es o ormit # acility Status Code oc.soil/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tank teel Fbrgl ng( Dual <br /> 111. TANK HISTORY <br /> as Tank tested? es o ailed precision test ? es o If yes, give date(s) / <br /> es a repair made to the tank system? Yes Na 11f yes, what was repaired, <br /> ns repair done under inspection? es 40 4ere soil samples analyzed? es 10TXE PH-G PH-D17b/EDB <br /> ype of failure/discharge atastrophic Fong-term leakage verfill nknownPther. <br /> IV.-kMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> ail Samples Received es VINO epth to Ground Water of/Year verage Annual Precipitation = 4 10-25 <br /> Site Wells) es o utter & Type Irr om ub <br /> S 9core S Score S Score <br /> i' tance to Welt(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts 1 <br /> 0 if 0 if 0 if i <br /> R ondition R condition R ondition <br /> 0.1 Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> i <br /> ihimum Depth to groundwater from the Soil Sample (feet) >100 51-100 25-50\1 <br /> .pctures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annuat Precipitation (inches) xxxxxx <10 9 10-25 KXXXxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> l!leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> Inique site features: Recharge area, coarse soil, nearby wells: At least 4ore than <br /> xxxx None one, one <br /> COLUMN TOTALS>>>TOTAL POINTS * ; <br /> 1�•p� ample Result: (B 7 X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 4$ is 40 pts or less'\ <br /> x e;=c,cj� <br /> g t � ¢L,0% 1= •O a7 r>, s T x E T E <br /> flyp{r� .� MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 59 50 50 .3 1. 1. NA\3 <br /> "C1 ample Result: ASOLINE 1000 00 10 <br /> AXIMUH ALLOWABLE TPN LEVELS (PPM) <br /> TPN 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 8TX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1, Are 8TX & E or TPH Concentrations > Allowable LevelsYes o j <br /> 2.. Recommend Site Closure es a If Yes, Refer to Site Mitigation far Evaluation <br /> VII. REVIEW EVALUATION - TO BE CC(IPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE E5 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURft LETTER MAILED <br /> AME OF --Z <br /> VALUATOR / �.j <br /> i <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />