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SAN JOAOUI 1NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H DIVISION <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY WEEPS CODE <br /> DRESS <br /> TANK ID # <br /> TANK SIZEUEL PE <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 tee( I Fbrgl ISNI Dual <br /> Ill. TANK HISTORY <br /> as Tank tested? es o ailed precision test ? es o If yes, give dates) <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> as repair done under inspection? es I No ere soil samples analyzed? 1Y <br /> es o TXE PH-G IT <br /> PH-D I li, <br /> b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfill nknown I lo <br /> ther: <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 of/Year verage Annual Precipitation = 4 0 25 <br /> Site Wells) es o umber -&--Type Irr FF1 <br /> ub <br /> S Score S Score S 3core <br /> istance to Well(S) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R ondition R condition R ondition <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) 35.. �5 >100 1-100 © 25-501 <br /> Fractures in subsurface (applies to foothills or mountain areas) !f- None Unknown resent <br /> Average 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 >resent <br /> pique site features: Recharge area, coarse soil, nearby wells. p At least ore than <br /> xxxxx None ! one one <br /> COLUMN TOTALS>>>TOTAL POINTS + is, <br /> + <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS19 pts or more 41 - 48 pts 40 pts or less <br /> B I T X E B JT X E <br /> 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 /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH DIESEL 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 /> 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 /> \3 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. 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 /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSUREES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED DATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />