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SAN JG, N COUNTY PUBLIC HEALTH SERVICES/ENVIRONMEN.. 1EALTH DIVISION <br /> 1• UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE O <br /> AME OF FACILITY Ij fdG /. C01-01,41A-or WEEPS CODE <br /> DRESS L v ANK ID p - 10 9 _ Lir <br /> TANK SIZE '� j UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> Is permit Current? eso ermit Y - acility Status Code oc.Soil/GW Cont iYes o <br /> umber of Tanks et facility ge of Tanks(if available) lype'of Tank Leel fbrgl ngl Dual <br /> 111. TANK HISTORY <br /> as Tank tested? es o1 IF ailed precision test es o If yes, give dates) <br /> as a repair made to the tank system? yes WoLl f yes, what was repaired? <br /> Jas repair done antler inspectionl es o ere soil canplea analyzed? es o �TXE PH-G PH D b/EDB <br /> Type of failure/discharge atastrophic lung-term leakage verflLl I kkmown ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soft Sarnplea Received es o epth to Ground Water of/Year �j; verage Annual Precipitation 4 0-25 <br /> -Site WeLL(s) es o umber t Type Irr I Jan ub <br /> S core S core S core <br /> istonce to Wells) from Tank ft; fc; ft C 10 pts C 9 pts C i pts <br /> 0 it 0 if 0 if <br /> W. R -ondition R condition R ondition <br /> Site feature - Leaching Potential Analysis E is mwt E is met E is met <br /> inio*4n Depth to groundwater fran the Soil Swiple (feet) >1UU 1-100 25-50 1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown 3resent <br /> verage Annual Precipitation (inches) xxxx <10 9 10-25 KXXAXXX 26-40L <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 ore than <br /> xxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS t <br /> 'ample Result: (B T X OR E) RANGE Of TOTAL POINTS 9 pts or gore 41 - 48 pts 40 pts or Less <br /> B T X E BT 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 /> IMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> OOINOTES: •■•!f documented soil and/or ground water contamination is present, do not caiplete the leaching potential <br /> analysis. (i.e., site is currently on UGI Contumination List for soil or ground water.) <br /> ,1 If depth is > 5 ft. and < 25 ft., score 0 points. It depth <_5 ft., do not use table. <br /> J2 If precipitation is > 40 inches, score 0 points. <br /> L Levrls for BTXdE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX t E or TPM Concentrations > Allowable levels Yes o •' <br /> 2. Recamend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> V11. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFEkRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> =VALUATOR <br /> Ell 23 8U (UGIWKSHT)\5/90 <br />