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SAN JOAW COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTA(E4EALTH DIVISION <br /> I' UGST WORKSHEET'FOR SITE CLOSURE EVALUATION DATE <br /> AME OF FACILITY 4r I r W U A-r e- .�_ O :JA <br /> EEPS CODE 3 <br /> ' DRESS CrE.�. / /I <br /> o b a L- r✓itS� g LNK ID # <br /> ANK SIZE IFUEL TYPIC <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? es o ermit # acility Status Code oc.Soil/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tank teel Fbrgl I 13nqL Dual <br /> III. TANK HISTORY <br /> as Tank tested? es o ailed precision test 7 es o If yes, give dates) <br /> as a repair made to the tank system?, es Naf yes, what was repaired? <br /> Jas repair done under inspection? .es o ere soil samples analyzed? es 0 TXE, PH-G PH-D b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfill noun ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es o epth to Ground water 4SO of/Year Cr� verage Arcual Precipitation <br /> -Site Wells) es o umber.& Type Irr an ub 1. <br /> S core 5 Score 5 Pcore <br /> istance to WeIL(s) from Tank ft; ft; ft C 10 pts C 9 pts C pts <br /> 0 if 0 if 0 f <br /> V. R ondition R condition R �ondltion <br /> Site Feature - Leaching Potential lAnalysis E is met E is metE s met <br /> inimum Depth to groundwater from the''SoiL Sample (feet) 2,100 1-100 25-5011 <br /> ractures in subsurface (applies to foothills or mountain areas) Hone Unknown >resent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 KXXxxxx 26-4012 <br /> an-Made conduits which increase vertical migration <br /> D4 leachate (i.e., septic systems, water wells, ponds) T None Unknown resent• <br /> nique site features: Recharge area,-coarse soil,.nearby wells. At least or than <br /> xxxx Noneone one <br /> COLUMN TOTALS>>>TOTAL POINTS (] + / 2— <br /> a le Result: (B T % OR RANGE OF TOTAL POINTS; 9 pts or more 41 - 48 pts 40 pts or less <br /> A10 ,OV71 C)/ 7- B r X E B r x E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 5 50 50 .3 .3 1. 1. NAL <br /> ample Result: ASOLINE 1000 100 10 <br /> IMUM ALLOWABLE TPH LEVELS (PPM) <br /> Al V1 TAH IESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soiL'�and/or ground water contamination is present, donot complete 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 < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> 12 If precipitation is > 40 inches, score 0 points. <br /> ,33 Levels for BT%&E are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel), <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations;> Allowable Levels <br /> Y INO <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED±.BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 I 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 />