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SAN JOAGU ANTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL 4H DIVISION <br /> 1' UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> � S7` <br /> AME OF FACILITY �, - 4. <br /> v'//,n r•/,: i .� WEEPS Cl - <br /> ODRESS <br /> �ANK ID <br /> ANK SIZE I TYPE (, <br /> If. GENERAL SITE HISTORY <br /> ** <br /> �umber <br /> feff <br /> ent? es o ermit # acility Status Code oc.Soi l/GLI Cont ess at facility ge of Tanks(if available) ype of Tank tee( Fbrgl ngl Dual <br /> Ill. TANK HISTORY <br /> M <br /> es o ailed precision test ? es o If yes, give date(s) <br /> to the tank system? es No f yes, what was repaired7 <br /> nder inspection? es o ere soil samples analyzed? es !o TXE PN-G PN-D b/EDD <br /> ischarge atastrophic long-term leakage verfill nknown Cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> .oil Samples Received es o ep[h to Ground water �. S of/Year SIS ;j verage Annual Precipitation = 4 10.25 <br /> 7 <br /> n-site Wel l(S) es o umber 8 Type Irr oo up <br /> S core S core S core <br /> istance to wells) from Tank ft; ft; ft - C 0 pts C pts C pts <br /> 0 if 0 if 0 'f <br /> R ordition R ondition 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 Sample (feet) )100 1-100 25.50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) 16, None Unknown resent <br /> verage Annual Precipitation (inches) xxxxx <10 9 10-25 xxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (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 /> xxxxx None one One <br /> COLUMN TOTALS>>>TOTAL POINTS �I? � �G <br /> X 6, <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 T X E <br /> MAXIMUM ALLOWABLE B•T•X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> -ample Result:� ASOLINE 1000 100 10 <br /> UU A%IMUM ALLOWABLE TPH LEVELS (PPM) <br /> 00 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 UCT 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 STX8E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> Vt. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPH Concentrations > Al [["wable Levels Ycs o I m. <br /> I2. Recommend Site Closure res I ro I V,l oHIf Yes, Refer to Site Mitigatial for Evaluation <br /> ``✓11. REVIEW EVALUATION • TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> ,ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE 'ES 10 I EFERRED TO SITE MITIGATION FOR EVALUATION ES 1a4O <br /> ATE REFERRED � <br /> ATE CLOSURE LETTE <br /> F <br /> -VALUATR MAILED / /EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />