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l <br /> ' f <br /> SAN JOAU '*COUN., PUBLIC HEALTH SERVICES/EMVIRONMENTAI �LTh DIVISION <br /> I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AHE OF FACILITY SWEEPS CODE 2 3 <br /> ODRESSo Z� TANK 1D # <br /> TANK SIZE IFUEL TYPE ���]jQ c� <br /> Tid- <br /> II. GENERAL SITE HISTORY a <br /> ** <br /> Is permit current? es: o ermit # acility Status Codeoc.SoillGW Cont es a <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tank teel brgt ngl I Dual <br /> 111. TANK HISTORY <br /> Was Tank tested? as o ailed precision test ? es o If yes, give date(s) <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> -ins repair done under inspection? es aere soil samples analyzed?1,es io TXE I PH-G PH-0 b/EDB <br /> ype of failure/discharge atastrophic long-term leakage v,rfi-ll I nknown ther: <br /> IV- REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es I IN01 epth to Ground Nater of/Year verage Annual Precipitation - 4 10-25 <br /> -Site Wells) es o umber & Type Irr am ub <br /> 5 core S core 5 core <br /> istance to Wells) from Tank ft; _f t; ft C 10 pts C 9 pts C pts <br /> 0 if 0 if 0 f <br /> R condition R condition R ondition <br /> Site feature - Leaching Potential AnalysisE is met E is met E s met <br /> inimum Depth to groundwater from the Soil Sampte (feet) .-100 1-100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown 01resent <br /> verage Annuat Precipitation (inches) xxxxx <10 4 10-25 xxxxxxx 26-40\2 <br /> nn-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown 3resent <br /> Inique site features: Recharge area, coarse soil, nearby wells. 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 /> B T X E B F X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: ASOLTHE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH—� IESEL 10.000 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 4=5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 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 $ E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluaeion <br /> VII. REVIEW EVALUATION - T;0 BE CCf4PLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATIDN FOR CLOSURE E5 0 EFERRED TO SITE MITIGATION FOR EVALUATION fES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> .VALUATOR <br /> EH 23 80 (UGTUKSHT)\5/40 <br /> EH 29 80 <br />