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o <br /> SAN JOAOU),__rJUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H DIVISION <br /> I• UGST WORKSHEET FOR SITE CLOSURE EVALUATION`"r ATE <br /> AME Of FACILITY _ C5 � yy)� WEEPS CODE <br /> DRESS co_QTANK ID # #� <br /> ANK SIZE 60 O 4 UEL TYPE S�-P <br /> II. GENERAL SITE HISTORY <br /> Is permit current? eso 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 ngl Dual <br /> Ill. TANK HISTORY <br /> as Tank tested? as INKo I IF ailed precision test ? es o If yes, give dates) <br /> Jas a repair made to the tank system? as No f yes, what was repaired? P� <br /> Jas repair done under inspection? es 0 ere soil samples analyzed? 1Yes =TXE PH-G I PH-D b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfill noun they: <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 0 of/Year verage Annual Precipitation <br /> -Site Well(s) es o X umber & Type 11r om ub <br /> S Score S Score S Score <br /> istance to Well(S) from Tank ft; ft; ft C 10 pts C 9 pts C i pts <br /> 0 if 0 if 0 if <br /> R ondition R condition R pondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 25-50L <br /> Fractures in subsurface (applies to foothills or mountain areas) /Q None Unknown resent <br /> verage Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40,2 <br /> an-Made conduits which increase vertical migration 'S(Jv� ,2,t,x,Q,v ' <br /> Df leachate (i.e., septic systems, water wells, ponds) None Unknown wlresent <br /> pique site features: Recharge area, coarse soil, nearby wells. At least 4ore than <br /> xxxxx None 9 one one <br /> COLUMN TOTALS>>>TOTAL POINTS <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or 48 pts 40 pts or less <br /> (o��b e°`^^� `i <br /> t? b $ e 1 r E B <br /> X <br /> x- MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50V50 SO .3 .T3 1. 1. NA13 <br /> Sample ResultASOLINE 10 100 }0 <br /> I IMUM ALLOWABLE TPN LEVELS (PPM) <br /> �'- TPH—r! IESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not ete the aching 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 /> ,2 If precipitation is > 40 inches, score 0 points. <br /> L 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 8 E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> V11. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR ,'. -L4":; <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE fS 0 EFERRED TO SITE MITIGATION FO! A{UA3I()!! ES I 0 <br /> ATE REFERRE - / / ATE CLOSURE LETTER MAILED J / <br /> AME OF f <br /> =VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />