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SAN JOAO COUh.. PUBLIC HEALTH SERVICES/ENVIRONMENTAL LT,. _,VISION <br /> i. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE 1 9 Z <br /> AME OF FACILITY EEPS CODE 1 Z✓ - <br /> DDRESS ANK ID # _ <br /> TANK SIZE 'L �(� �� UEL TYPE <br /> 11. GENERAL SITE HISTORY,i <br /> ww <br /> Is permit current7 esi o ermit IFacidity Status Code oc.Scil/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tank Tel Fbrgl ngl Dual <br /> III. TANK HISTORY <br /> as Tank tested? es o ailed precision test ? es o If yes, give date(s) <br /> Was a repair made to the tank system? es No f yes, what was reired? <br /> pa <br /> ns repair done under inspection? es 4 4ere soil samples analyzed? es Io TXE PH-G PH-0 b/EDB <br /> ype of fallure/dischaelge atastrophic long-term leakage verfill nknown then: <br /> 1V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> i <br /> oil Samples Received .es o epth to Ground Nater of/Year verage Annual Precipitation = 4 10-25 <br /> Site WeIE(s) es i o umber & Type Irr am ub <br /> 5 core S core S core <br /> istance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C pts <br /> 0 if 0 if 0 "f <br /> R bonciftion R condition R ondition . <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E s met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown >resent <br /> verage Annual Precipitation (inches) KiXXXX <10 9 10-25 xxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., sept'.ic systems, water wells, ponds) None Unknown resent <br /> lnique site features: ' Recharge area, coarse soil, nearby Hells: At least 4ore than <br /> xxxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS + + <br /> ample Result: B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> �= e) ND .d25 i <br /> T- l 9Pi°"KA 7.9fPolk: - B TX E B JT X E <br /> MAXIMUM ALLOWABLE A-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Rc ult- ASDLINE 1000 100 10 <br /> CEO= iPPm '� AXIMUM ALLOWABLE TPN LEVELS (PPM) <br /> #I2—12.0e4M TPHds 1ESEL107o00 1000 100 <br /> OOTNOTES: ***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, scare 0 points. <br /> \3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH'Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure es o If Yes, -Refer to Site Mitigation for Evaluation <br /> v1I. REVIEW EVALUATION - i0 BE COMPLETED BY A SUPERVISOR/SENIOR <br /> i <br /> .ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / ' ATE CLOSURE LETTER MAILED <br /> aME OF <br /> .VALUATOR i <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> -H 29 80 <br />