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SAN JOAOUtX COUNTY' (LIC HEALTH SERVICES/ENVIRONMENTAL HEALTH 01V13E09 GATE 7i <br /> UGS:�yXSHEET FOR SITE CLOSURE EVALUATION <br /> SWEEPS CODE <br />;4AME OF FACILITY <br /> TANK ID $ <br /> IA00RESS <br /> TANK SIZE FUEL TYPE <br />'I. GENERAL SITE HISTORY <br /> Is permit current? Yes No T ormit it <br /> Facility Status Code Doc.Soit/GW Cont Yes No <br /> Number of Tanks at facility <br /> Aye of tanks(if available) Typo of tank Steel Fbr9l Sngt Oual <br /> tit. TANK HISTORY <br /> es ive dates) <br /> PM test T Yes No <br /> Was Tank tested? Yes No Failed pIf y , 9 <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? <br /> TPH-01 Pb/E08 <br /> was repair done under inspection? Yes No Were soil saaples analyzed? Yes No BTXE TPH-G <br /> Type of failure/discharge catastrophic long-term leakage overfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Sail Samples Received Yes No Depth to Ground Water /;� Ref/Year ; <br /> Average Annual Precipitation A= 14 10-25Annual <br /> On-Site Wells) Yes No Number b type Err Dom Pub <br /> S Score S Score S Score <br /> Distance to Wett(s) from Tank �h ft; ft; ____ft C 10 pts C 9 pts CO 5fpts <br /> 0 if 0 if <br /> R condition R condition R condition <br /> V. Site Feature - Leaching Potential Analysis <br /> E is met E is met E is met <br /> , L� 25-50\1 <br /> um <br /> jminimOepth to groundwater from the Soil Sample (feet) �� ;a >100 51-100 <br /> Norte c-r Unknown Present <br /> (Fractures in subsurface (applies to foothills or mountain areas) <br /> I <br /> Average Annual Precipitation (inches) <br /> xXXx�cx <10 9 10-25 xxxxxxx Z6-40\2 <br /> Man-made conduits which increase verticat migration ) NWe Unknown Present <br /> of leachate (i.e., septic systems, water wells, ponds <br /> At least � More than <br /> Unique site features: Recharge area, coarse soil, nearby welts• xxxxxx None one one <br /> COLUMN TOTALS>»TOTAL POINTS <br /> Sample result: (B T X OR E) <br /> RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> e TX E 8 T X E <br /> r=•ao��/y+ V•D- MAXIMUM ALLOWABLE B-T-X•E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. <br /> GASOLINE 1000 100 10 <br /> Sample Resutt: <br /> MAXIKA ALLOWABLE TPH LEVELS (PP") DIESEL 10,000 1000 100 <br /> /7[:% =� <br /> _/�. TPH-%� <br /> FOOTNOTES: <br /> ' ***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 /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth 4=5 ft., do not use table. <br /> \2 if precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTXLE are not applicabla at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are 3TX b E or TPH Concentrations > Allowable Levels 'Yes ✓ No <br /> Z. Recommend Site Closure Yes No If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO 3E COMPLETED 8Y <br /> A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE TES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> 0 <br /> LOATEREFERRED2DATE CLOSURE LETTER MAILED /R <br /> EH 23 30 (UGTWXSHS)\5/90 <br />