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SAN JOAOUiU.jTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL ham,).i DIVISION <br /> 1 UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE I r I <br /> AME OF FACILITY �-l!�- EEPS CODE <br /> IDDRESs ` 5 TANK 10 # <br /> FAHK SIZE UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> +w <br /> Is permit current? es a ermit # acility Status Code oc.Soil/GH cont es o <br /> umber of Tanks at facility ge of Tanks(if available) IType of Tank teel Fbrgl ngl Dual <br /> 111. TANK HISTORY <br /> 'as Tank tested? es o ailed precision test ? es FOT If yes, give date(s) <br /> Jas a repair made to the tank system? es No f yes, what was repaired? <br /> iis repair done under inspection? esit <br /> ere soil samples analyzed? es to TXE PH-G PH-D blEDB <br /> ype of failure/discharge atastrophicg-term leakage verfill nknown I lather: <br /> 1V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es o epth to Ground Water of/Tear verage Annual Precipitation = 4 10-25 <br /> -Site Well(s) es I o I umber 8 Type lrr om ub <br /> S coreS core 5 core <br /> Distance to Well(s) from Tank ft; ft; ft C 0 pts G pts C pts <br /> 0 f 0 if 0 if <br /> R ondition R condition R ondition <br /> Site Feature - Leaching Potential Analysis E is met E is met E s met <br /> inimum Depth to groundwater from the Soil Sarple (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) KXXXXX <10 9 10-25 xAAxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> Df teachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> lnique site features: Recharge area, coarse soil, nearby wells. _ At least ore than <br /> xxxx 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 /> BI. i X E 8tT XMAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 1. 1_ NA\3 <br /> -ample Result: ASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL j 10,000 1000 100 <br /> FOOTNOTES: ***If documented snit 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 paints. If depth <25 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for STXBE are not applicable at a TPH concentration of TO ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1, Are BTX 8 E or TPH Concentrations > Allowable Levels Yes I lNot <br /> 2. Recommend Site Closure es o 1f Yes, Refer to Site Mitigation for Evaluation % <br /> Vt[. REVIEW EVALUATION TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> .CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE fES O 1 aEFERRED TO SITE MITIGATION FOR EVALUATION fES 0 <br /> DATE REFERRED / / ATE CLOSURE LETTER MAILED / 1 <br /> AME OF <br /> VALUATOR <br /> SH 23 80 (UGTWKSHT)\5/90 <br /> H 29 80 <br />