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SAN JOAOUI+ COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTA r c�_AH OIVISION ATE <br /> I, UGST WORKSHEET FOR SITE CLOSURE EVALUATION` g J <br /> AME OF FACILITY WEEPS CODE <br /> CIC i /67/ <br /> US <br /> DRESS - Rea <br /> � oTANK ID # s"WO <br /> cu /COQu <br /> TANK SIZE I E2a2UEL TYPE Uu Q i1 <br /> II. GENERAL SITE HISTORY •• <br /> Is permit current? es o ermit # - acility Status Code S( oc.Soit/GW Cont es V/ o <br /> umber of Tanks at facility kge of Tanks(if available) `S'- ype of Tank ISteel Fbrgl ngl I Dual <br /> 111. TANK HISTORY <br /> Jas Tank testedt es o ailed precision test 7 es o j/If yes, give date(s) <br /> Jas a repair made to the tank system? IYes No IS 11f yes, what was repaired? <br /> as repair done under inspection7 es 4o ere soil samples analyzed7 es o t TXE PH-G PH-D I b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfill nown ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPO T F S 1E DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Wo <br /> oil Samples Received es o )C epth to Ground Water �S of/Year S verage Annual Precipitation 4 0-25 <br /> -Site Wells) es o I V�umber b Type Irr cm ub <br /> S core S Score S core <br /> istance to Welts) from Tank ft; ft; ft C 0 pts C pts C pts <br /> 0 if 0 if O f <br /> R condition R zondition R ondition <br /> 1. Site Feature - Leaching Potential Analysis E is met E is met E s met <br /> inimum Depth to groundwater from the Soil Sample (feet) 3�� >100 1-100 JT- 25-5011 <br /> ractures in subsurface (applies to foothills or mountain areas) None CI unknown resent <br /> verage Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40_\2 <br /> an-Made conduits which increase vertical migration <br /> Df leachate (i.e., septic systems, water wells, ponds) None 9 Unknown resent <br /> ique site features: Recharge area, coarse soil, nearby welts. At least ore than <br /> xxxx None 9 one one <br /> COLUMN TOTALS»>TOTAL POINTS * 36 ' <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS E9 pts or more 41 48 pts 40 pts or less <br /> .008 PRAT X ,ogrPP <br /> r,o63PPM Lc,00gPP B T X E B TJX EMAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .31. 1. NAL <br /> ample Result: ASOLINE 1000 100 10 <br /> IMAJM ALLOWABLE TPN LEVELS (PPM) 100 <br /> ft�.� TPH j> IESEL 10,000 1000 <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 /> 11 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 /> 13 Levels for BTXEE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION f <br /> 1. Are BTX L E or TPH Concentrations > Allowable Levels Yes o �QS"` �� O�/y <br /> 2. Recommend Site Closure IYes o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER IMILED / / <br /> AME OF <br /> "VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />