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.I. I <br /> rt =� <br /> SAN JOAOI,-. JNTY PUBLIC HEALTH SERVICES/EHYIRQHMENTALH DiYISIQN - 19 <br /> i, UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE y <br /> i t <br /> i. <br /> r <br /> OF FACILITY r� ' 44_ �/V EPS CODE �a <br /> ESS a 'sa � ANK 11) <br /> SIZE a O Q UEL TYPE Q SO J1 Cu?l,Q�WdC/G�j <br /> II. GENERAL SITE HISTORY , <br /> !s permit current? es a V ermit # lFaciLity Status Code I IDoc.SoiL/GW Cont es o <br /> i <br /> umber of Tanks at facility kge of Tanks(if available) ype'of Tank feel ZFbrgt I ngl Dual <br /> III. TANK HISTORY <br /> Jas Tank tested? es o ailed precision test 7 eso if yes, give datea2/.As) x/,?]; <br />' as a repair made to the tank system? 1Y Ies No t yes, what was repaired? e Ido u SE3�( Q r r O c ee <br /> i. <br /> as repair done under inspection? es o ere soil samples analyzed? es o TXE PH-G PH-D b/EDB <br /> l <br /> ype of failure/discharge ataStrophic long-term leakage verfill known they: <br /> IV. REMOVAL HISTORY (ATTACH INSP CTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received 1Yes o I 13epth to Ground Water of/Y.ear 14verage Annual Precipitation = 4 0-25 <br /> -Site Wells) es o umber & Type Irr om ub <br />[ S Core S core S core <br /> I istance to Well(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> k. 0 if 0 if 0 if <br /> R ondition R condition i. R ondition <br /> 1. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> 1' inimu. Depth to groundwater from the Soil Sample (feet)dfQ >100 1-100 $ 25-50L <br /> ractures in subsurface (applies to foothills or mountain areas) D None Unknown 3resent <br />{ verage Annual Precipitation (inches) KXXXXX 00 9 10-25 KXXXXXX 26-4412 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> ique site features: Recharge area, coarse soil, nearby wells. At least 4ore than <br />! xxxx None one one <br /> a <br /> COLUMN TOTALS»>TOTAL POINTS <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTSf9 pts or more 41 - 48 pts 40 pts or less <br /> BT X E B JT X E <br /> MAXIMUMALLOWABLE B-T-x-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA13 <br /> ample Result: SOLINE 1400 100 10 <br /> IMUM ALLOWABLE TPH LEVELS (PPM) <br /> -�• � TPH 1ESEL 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 /> if precipitation is > 40 inches, score 0 points. <br /> _ Levels for BTX&E are not applicable at a TPH concentratiori of 10 ppm (gasoline) or 100 ppm (diesel). <br /> �. VI. STAFF RECOMMENDATION/CONCLUSION „j •' <br /> 1. Are BTX & E or TPH Concentrations > Alto wab a Levels Ygs o <br /> E' <br /> f 2. Reconnerd Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> VI1. 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 i <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> I <br />