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SAN JOAOUI. JUMTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H DIVISION <br /> # I. -- UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> [ANK <br /> OF FACILITY WEEPS CODE <br /> ESS ANK 10 q <br /> �r2ccic�F LbN�S <br /> SIZE e. <br /> UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> ** <br /> Is permit current? td <br /> o ermit R - cility Status Code oc.Soil/GW Cont es a <br /> umber of Tanks at cility ge of Tanks(if avaitabte) ype of Tank feel Fbrgi ngl Dual <br /> III. TANK HISTORY <br /> as Tank tested? es o ailed.precision testi es o If yes, give date(s) <br /> Jas a repair made to the tank system? es No f yes, what was repaired? <br /> as repair done under inspection? es o ere soil samples analyzed? es a TXE PH-G PH-O b/EDB <br /> ype of failure/discharge atastrophic long-term leakage ve fi[t mown I lother: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> i <br /> oil Samples Received es I o epth to Ground Water of/Ye r ; verage Annual Precipitation a 4 0-25 <br /> -Site Welt(s) es o umber & Type Irr I om ub <br /> 5 Score S Score S core i <br /> istance to Welts) from Tank ft; ft; ft C 10. pts C 9 pts C pts <br /> 0 if 0 if 0 f <br /> R ondition R condition R ondition j <br /> Site Feature - Leaching Potential Analysis E is met E is met E s met 11 <br /> 1 <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 25-50L � <br /> ractures in subsurface (applies to foothills or mountain areas$ None Unknown resent <br /> verage Annual Precipitation (inches) xxxxxx c10 9 10-25 KXXxxxx 26-40V <br /> an-Made conduits which increase vertical migration <br /> Df leachate (i.e., septic systems, water wells, ponds) None Cl Unknown Present <br /> pique site features: Recharge area, coarse soil, nearby wells. At least lore than <br /> xxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS + + <br /> Sample Result: CO T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> B T X E B I T [qE <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 5Q 50 50 .3 .3 1. NAL <br /> Sample Result: ASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented so <br /> it 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 /> ,LT If depth is > 5 ft. and < 25 ft., score 0 points. f depth ­5 ft., do not use table. <br /> N2 If precipitation is > 40 inches, score 0 paints. <br /> 13 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 Yes <br /> 2. Recommend Site Closurees o If Yes, Refer to Site Mi igation for Evaluation <br /> V11. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES=EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / ATE CLOSURE LETTER MAILED <br /> AME OF _[ <br /> -VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />