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LTH DIVISION <br /> SAN JOAOUtn COUNTY PUBLIC HEALTH SERVICES/ENVERONMEN7Ar..� DATE S <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> I. <br /> C <br /> NAME OF FACILITY SWEEPS COOE <br /> - <br /> TANK ID ar <br /> ADDRESS <br /> TANK SIZE FUEL TYPE <br /> I. GENERAL SITE HISTORY <br /> ty Status Code D°C.Soit/GST <br /> Is permit current? Yes No <br /> ermit - FaciliCont Yes No <br /> Number of Tanks at facility 01- <br /> Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Oual <br /> III. TANK HISTORY /e / <br /> r No If yes, give date(s) <br /> ` 1 / , <br /> Was Tank tested? Yes [ No Failed precision test ? Yes <br /> was a repair made to the tank system? Yes No If yes, what was repaired? <br /> Was repair done under inspection? Yes No Were soil samples analyzed? Yes No BTXE TPH-GI TPH-D Pb/ED3 <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 /> to Ground Water Ref/Year ; <br /> Average Annual Precipitation A= 14 10-2 <br /> Soil Samples Received Yes No Depth <br /> On-Site WeLt(s) Yes No Number & Type Irr Dom Pub S Score S Score S Score <br /> ft C 10 pts C 9 pts C 5 pts <br /> Distance to Well(s) from Tank <br /> ft; ft% 0 if 0 if 0 if <br /> R condition R condition R condition <br /> E is met E is met E is met <br /> V. Site Feature - Leaching Potential Analysis is met s met 1 <br /> >100 <br /> Minimun Depth to groundwater from the Soil Sample (feet) Unknown Present <br /> None <br /> Fractures in subsurface (applies to foothills or mountain areas) <10 9 . no xxxxxxx resent2 <br /> xxxxxx <br /> Average Annual Precipitation (inches) <br /> Man-Made conduits which increase vertical migrati°nds) <br /> None Unknown Present <br /> of leachate (i.e., septic systems, water wells, P° At least) More than <br /> Unique site features: Recharge area, coarse soil, nearby wells. xxxxxx None <br /> 1 one one <br /> COLUMN TOTALS>>>TOTAL POINTS t <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or Les <br /> B T X E B T X E NA\3 <br /> 3 MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 10 <br /> GASOLINE 1000 100 <br /> Sample Result: 1000 100 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) DIESEL 10,000 <br /> L� � TPHotentia <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the leaching p <br /> analysis. (i•e•, site is currently on UGT Contamination List for <br /> nso*it ortabl� water.) <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 pontss. If depth <=5 ft., <br /> ot <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTXBE are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION N A� <br /> 1. EArejBTX b E or TPH Concentrations > Allowable Levels *YesNO2. d Site Closure Yes No if Yes, Refer to Site Mitigation for Evaluation <br /> VIE. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE CLOSURE LETTER NAILED <br /> DATE REFERRED <br /> NAME OF <br /> EVALUATOR <br /> gm ?9 A0 (UGTVKSHT)\5/90 <br />