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�+ I- SAN Ji�,o,., 'N COUNTY PUBLIC kE�ERViCES/ENYIRONMEN ,•�C;EALTH DIVISION <br /> UGST WORKSHEET FOR SITE CLOSURE I EVALUAI'' pTE ri <br /> SIAME OF FACILITY �'ew r If fV�14 <br /> + EEPS CODE / el <br /> DRESS �} J <br /> OS � � �. Q�y�� ���` � ANK 1p f1 - l3 y —d <br /> L512E /0 0 D UEL TYPE ` <br /> I.I. GENERAL SITE HISTORY <br /> Is permit current? as o ermit it *w <br /> 3 9 - ao /3 yy acil;ity status Code p/ x.Soil/GLI Cant esTF <br /> o <br /> umber of Tanks at facility ge of Tanks(if availab(e) ! 2LJype of Tank teal Fbrgirx)l Dual <br /> III. TANK HISTORY js <br /> prepatrid2,n,�:rtlinspe <br /> ? <br /> as o ailed precision test ? es o If yes, give decals) / <br /> e tank system? es No f yes. what was repaired? <br /> ction? es o ere soil sanptes analysed? es o TXl PH-G PH-0 b/Ep8 I <br /> ype of failure/discharge atastrophic fang-term Leakage verfillrwwn Cher: <br /> I <br /> IV. REMOVAL HISTORY (ATTACH INSP CTION REPORT FOR SITE DETAILS/COLLECT DATA4OR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es o epth to Ground dater of/Y <br /> U ear96 ; Verage Annual Precipitation 4 0-25 <br /> -Site IIeIL(s) es o umber $ Type 11r am ub l <br /> istance to 11e11(s) from Tank S core S core S core <br /> ft; ft; ft C0 pts C 9 pts C pts } <br /> OIf if 0 if 0 if <br /> Site Feature - Leaching Potential Analysis R i orditian R ondition R ondition <br /> E i! i s n+et E is met E is met <br /> iniowrn Depth to groundwater from the Soil Sample (feet) .." 3� ,1 >100 <br /> 1-100 25 5011 <br /> ractures in subsurface (applies to foothills or mountain areas) £ None ! <br /> Unknown resent <br /> verage Annual Precipitation (inches) xxxx <10 9 10-25 itxxxxxx 25-40L2 <br /> an-Made conduits which increase vertical migration 'E <br /> f Leachate (i.e., septic systems, water wells, ponds) None <br /> Unknown resent <br /> ique site features: Recharge area, coarse soil, nearby wells. f <br /> O At least ore than <br /> xxxx None ! one one <br /> COLUMN TOTALS»>TOTAL POINTS" + + <br /> �7 b7 <br /> ample Result: (B T X OR E) <br /> RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> Y 7 5 <br /> t Ue 7,�~,y Q� 1 <br /> 1 B jT X E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 ,3 .3 1. 1. � NA�3 <br /> ample Result: <br /> NE <br /> + IMUM ALLOWABLE TPN LEVELS (PPM) SOLI 11000 100 10 <br /> TPN <br /> )LI ESEL ;10,000 1000 100 <br /> OOTNOTES: .r*I documented soil and/or ground water contamination is;present, do not ca+ipiete the Leaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> L If depth is > 5 ft. and c 25 ft., score 0 points. If depth 4=5 ft., do not use table. <br /> 12 If precipitation is > 40 inches, score 0 points. <br /> 13 Levels for BTX&E are not appticabte at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION /17 <br /> 1. Are BTX & E or TPH Concentrations > Attowabte Levels Yes o <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation 4 <br /> V11. REVIEW EVALUATION - TO SE COMPLETED BY A SUPERVISOR/SENIOR � <br /> DNCUR <br /> WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION YES0 <br /> ATE REFERRED (!' / �/ /Gi J ATE CLOSURE LETTER MAILED <br /> AME OF _ + <br /> =VALUATOR <br /> EH 23 80 (UGTNKSHT)15/9Q ;} <br />