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SAN JOAOUI0��'XJN„ PUBLIC HEALTH SERVICES/ENVIRONMENTAL IF <br /> kaTti. --VISION <br /> I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE 2—17--9-1 <br /> AME OF FACILITY SWEEPS CODE 12_5 <br /> DDRESS TANK ID # <br /> TANK SIZE �i UEL TYPE P P�3 P <br /> 11. GENERAL SITE HISTORY � l'�,n' '7 <br /> ! ra <br /> Is permit current? as it o ermit p acitity Status Code oc.Soil/GW Cont as o <br /> umber of Tanks at facitiity ge of Tanks(ff available) ype of 'Tank teel Fbrgl ngl Duet <br /> 111. TANK HISTORY <br /> Was Tank tested? es I lio 1 IFailed precision test ? es a If yes, give dates) / <br /> Was a repair made to the; tank system? es No 11f yes, what was repaired? <br /> ns repair done under inspection? es o ere soil samples analyzed7 as toTXE PH-G PH-0 b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfilt nknown ther: <br /> IV, REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA-FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received as a epth to Ground.Water of/Tear verage Arcual Precipitation = 4 10-25 <br /> -Site wet t(S) es o umber 8 Type Irr om ub <br /> 5 Score 5 Score 5 cora <br /> (stance to Wetl(s) fro(WTank ft; ft.; ft C 10 pts C pts C pts <br /> 0 if 0 if 0 f <br /> ! Rcondition R condit!on R ondition <br /> Site Feature - Leaching Potential Analysis E is met E is met E 's met <br /> inimun Depth to groundwater from the Soil Sanpie (feet) >100 1-100 25-50\1 <br /> ractures in subsurface tapplies to foothills or mountain areas) None Unknown resent <br /> ! <br /> verage Arcual Precipitation (inches) KXXXXA A10 9 10-Z5 xxxxxxx 26-40\2 <br /> zn•Made conduits which increase vertical migration <br /> Df leachate (i.e., septic systems, water wells, ponds) None Unknown PIresent <br /> lnique site features: Recharge area, coarse soft, nearby welts: At least lore than <br /> xxxxx None one one <br /> COLUMN TOTALS »TOTAL POINTS + + <br /> Le Resu t: (B T ORIF) RANGE',OF TOTAL POINTS <br /> 9 pts or, more 41 - 48 pts 40 pts or less <br /> =' MAXIMUM ALLONABIE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> a ie ResUla:__ -. ASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH-b IESEL 10,000 1000 100 <br /> OOTNOTES: "" if documented soft and/or ground water contamination is present, do not complete the leaching potential <br /> analysis. (i.e., sfte 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 (gasotine) or 100 ppm (diesel). <br /> V1. STAFF RECOMIIENDATION/CONCLUSION <br /> 1, Are BTX S 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 /> .CNCUR WITH STAFF RECOMMENDATION FOR CLOSUREES 0 EFERRED TO SITE MITIGATION FOR EVALUATION E5 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED / / <br /> AME OF <br /> .VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90. <br /> Ell 29 80 , <br /> �� 1 <br />