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SAN JOAOUIkNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL IItH DIVISION p <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE [ ZZ QZ <br /> AwE CFL WEEPS CODE <br /> DDRESSZ j/j ANK ID # <br /> i tro <br /> TANK SIZE 1FUEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> ww <br /> Is permit current? es o ermit # acility Status Code oc.Soi l/GW Cont es o <br /> umber of Tanks at facility Be of Tanks(if available) ype of Tank 1,teel Fbrgl I 1,n9t Dual <br /> III. TANK HISTORY <br /> as Tank tested? as o ailed precision test ? es I ito If yes, give date(s) <br /> as a repair made to the tank system? as No 11f yes, what was repaired? <br /> as repair done under inspection? as o ere soil samples analyzed? es Io I TXE PH-G PH-D b/EDB <br /> Type of failure/discharge atastrophic long-term leakage verfitl nknown 1 13ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> soil Samples Receivedes o epth to Ground Water d of/Year $ O verage Annual Precipitation 4 10.25 <br /> )n-Site Wells) es o I umber 8 Type Irr an I ub <br /> S Score S Score S Score <br /> istance to Well(s) from Tank ft; _f t; ft C 10 pts C 9 pts C 5 pts <br /> ' 0 if 0 if 0 if <br /> R onli tion R condition R ondition <br /> V. Site Feature - Leaching Potential Analysis 4.O-3 _3'1 ' E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 S— 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) Io None Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 xxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) �� None Unknown Present <br /> inique site features: Recharge area, coarse soil, nearby wells. q At Least ore than <br /> xxxxx None / one one <br /> COLUMN TOTALS»>TOTAL POINTS p <br /> ample Result: (5 T X OR E) RANGE OF TOTAL POINTS F9 pts or more 41 48 pts 40 pts or less <br /> urggl -T,c B T X E 8 T I % E <br /> Df(�elC, E.o i� yr1 MAXIMUM ALLOWABLE B•T•X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> -ample Result: ASOLINE 1000 100 10 <br /> V0 'D Ak s pp M A%IMUM ALLOWABLE TPH LEVELS (PPM) <br /> I ITPH IESEL 10,000 1000 100 <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 /> \1 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 /> \3 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION �. I�i-M1 1 <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o 'Vl.i l CLuC�Jlf!GcG �GTCC ��� <br /> 2. Recommend Site Closure as o If Yes, Refer to Site Mitigation for Evaluation <br /> Vil. REVIEW EVALUATION , TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> ,ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> )ATE REFERRED / z,Z/ ATE CLOSURE LETTER MAILED <br /> 2VALUATOR � � �t / <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />