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i <br /> SAN JCI :OUNTY PUBLIC HEALTH SERVICES/ENVIRONMENT' LTH DIVISION <br /> !• UGST WORKSHEET FOR SITE CLOSURE EVALUAToATE 9_—/ <br /> �Q <br /> IANE Of FACILITY ! WEEPS CODE a <br /> DRESS sa . TANK ID R 4 - <br /> ANK SIZE IFUEL TYPE s <br /> il. GENERAL SITE HISTORY <br /> ri► <br /> Is permit currant? es o ermit * acility status Code oc.Soil/GW Cont es o <br /> umber of Tanks at facility We of Tanks((f available) IType of Tank IS teel Obrgt ngl Dual <br /> III. TANK HISTORY <br /> Jos Tank tested? es o ailed precision test ? es o If yes, give dace s) ,aa 47, <br /> as a repair made to the tank system? es No f yes, what was repaired? m leased Gt'ir O G ee ft <br /> Jas repair done under inspection? es o ere soil samples analyzed? es o TILE PH-G PH^D b/EDB <br /> ype of failure/discharge atastrophic long-term leakageVertill norm lather: <br /> IV. REMOVAL HISTORY (ATTACH INSP5FTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> ail Samples Receivedes a epth to Ground Water A/o of/Year ; ; verage Annual Precipitation <br /> -Site Wet l{s) es o umber & Type irr _ am ub <br /> 5 Score S Score S core <br /> istance to Welt(s) from Tank ft; ft; ft C 10 pts C pts C pts <br /> 0 if O if 0 if <br /> R randition R condition R ondition <br /> 1. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet)8 >100 1-100 25-501 <br /> ractures in subsurface (applies to foothitls or mountain areas) f3 None Unknown resent <br /> verage Annual Precipitation (inches) xxxx 410 9 10-25 xxxxxxx 26-40.\2 <br /> Ian-Made conduits which increase vertical migration <br /> at leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> ique site features: Recharge area, coarse.,soit, nearby wells. At least 4ore than <br /> Kxxxxx None one one <br /> i y <br /> COLUMN TOTALS»>TOTAL POINTS <br /> ampte Result: (8 T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> s �c I rC= q,31 <br />' rs 71,6 X 5�c� MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 T.3 1. 1. NA.\3 <br /> 4' <br /> ample Result; SOLINE 1000 100 10 <br /> GIIMUM ALLOWABLE TPH LEVELS (PPM) <br /> .-� TPH IESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented Boit 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 /> _\_I If depth is > 5 ft. and < 25 ft., score 0 points. It depth 4_5 ft., do not use table. <br /> •L2 if precipitation is > 40 inches, scare 0 points. <br /> Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels 4es o <br /> ' 2. Recommend Site Closure es o V If Yes, Refer to Site Mitigation for Evatuetian <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE tES I 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> E ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> I <br /> AME OF <br /> t "VALUATOit <br /> EH 23 80 (UG1WKS"T)%5/90 c <br /> i <br /> i <br />