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1 <br />'4, F SAN JOAO COUh., PUBLIC HEALTH SERVICES/ENVIRONMENTAt��"LT�P. -1VlSIDN <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION"" ATE _ 12_<?- <br /> Z_ <br /> AME OF FACILITY EEPS CODE y 3 7- <br /> ODRESS zANK ID gtAl IT <br /> t! <br /> TANK SIZE !`L h UEL TYPE �/� � �� 1/ 13 <br /> It. GENERAL SITE HISTORY <br /> Is permit current7 cs o ermit if lFaciLity Status Code I JDoc.Soil/GW Cont 1Yes o <br /> umber of Tanks at facility ge of Tanks(if available) ype of lank Leel Fbrgl ngl Dual <br /> 111. TANK HISTORY <br /> as Tank tested? es o ailed precision test ? es oIf yes, give date(s) <br /> Jas a repair made to the tank system? es No f yes, what was repaired? <br /> ns repair done under inspection7 es o ere sail samples analyzed? es la TxE PH-G H-0 EDB 00, <br /> ype of failure/discharge atastropttie long-term leakage -F,7 <br /> erfill nknown ther: <br /> IV, REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es 1401 epth to Ground Water of/Yenr� 8�; verage Annual Precipitation = 4 10-25 <br /> -Site Wett(s) es 0 umber & Type I ✓Irr om ub <br /> S Score S Score S Score <br /> istance to Welt s) from Tank 00-rft; -f t; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R condition R condition R ondition <br /> W. 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 Q 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) 0 None Unknown resent <br /> verage Annual Precipitation (inches) xxxxxx <10 9 10-25 KXXxxxx 26-40\2 <br /> ars-Made conduits which increase vertical migration <br /> f Leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> In(que site features: Recharge area, coarse soil, nearby wells: At least ore than <br /> xxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS r O + j S + <br /> 35 <br /> ample gssu) t: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts. or less <br /> 13T E Qn® -025 p pvA a T x le it Jr x E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result:TP0-(1 ASOLINE 1000 100 10 <br /> A%CHUM ALLOWABLE TPH LEVELS (PPM) <br /> TRH IESEL 10,000 1000 100 <br /> OOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the leaching potential <br /> anatysis. (i.e., site is currently on UGT -Contamination List for soil or ground water.) <br /> \1 Ifj depth is > 5 ft. and < 25 ft., score 0 points. If depth r_5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 4 points. <br /> \3 Levets for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (dieset). <br /> V1. STAFF RECOMMENDATION%CONCLUSION <br /> 1, Are BTX & E or TPN Concentrations > Allowable Levels Yes ✓ o, <br /> i <br /> 2. Recommend Site Closure 1Yes o ]f Yes, Refer to Site Mitigation for Evaluation <br /> VII, REVIEW EVALUATION -i 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 /> 5, <br /> ATE REFERRED r % / ATE CLOSURE LETTER MAILED <br /> AM£ OF <br /> -.VALUATOR <br /> E <br /> VALUATOREH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />