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j{ SAN JOt�lN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENHEALTH DIVISION d <br /> 1' UGST WORKSHEET FOR SITE CLOSURE EVALUATION - ATE O �I �Qq' <br /> AME OF FACILITY 0 on PCZ WEEPS CODE TE ( 3 <br /> DRESS q25 N . Un ��✓� <br /> F� ^ , AUK ID # ' <br /> ANK SIZE 500 wt-L UEL TYPE D <br /> - 11. GENERAL SITE HISTORY <br /> /y i <br /> Is permit current? es o ermit # - acility Status Cale D—t oc-Soil/GW Cont e b <br /> I <br /> umber of Tanks at facility L` ge of Tanks(if available) UNC ype of Tank Leel Fbrgl <br /> ngl Dual" <br /> III. TANK HISTORY <br /> M <br /> es o ailed precision ;est7 es o If yes, give dates)to thtk f yes, what was repaired? <br />�- nder inspection?-ttes,. o ere soil samples analyzed? es o TXE H-G PH-D <br /> /ED8 <br /> ischarge atastrophic long-term leakage verfilL noun Cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oit Samples Received es o epth toGround Water � of/Year 1'7 P_ verage Amual Precipitation = 4 0-25 <br /> -Site WeLL(S) es )( o umber 8 Type t Irr OM ub 1�! ` <br /> S Score S core S core <br /> istance to Wells) from Tank ft; ft; l�nK• ft C 0 pts C 9 pts C pts <br /> 0 if 0 if 0 "f D <br /> R ondition R onditim R ondition <br /> Mconduits <br /> re - Leaching Potential Analysis - E is met E is met E 's met <br /> to groundwater from the Soil Sample (feet) 3522=Ij >700 1-100' O 25-5011 D <br /> bsurface (applies to foothills or mountain areas) 6 More Unknown resent <br /> AnnualPrecipitation (inches) xxxxx <10 9 10-25 xxxmx 26-4OL2 <br /> ts which increase vertical migration - <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown 5 resent <br /> nique site features: Recharge area, coarse soil, nearby wells. At least ore than <br /> xxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS I0 ♦ ( + 32 <br /> ample Result: (B T X OR E)) RANGE OF TOTAL POINTS <br /> FS-1 22' 9 pts or more 41 - 48 pts 40 pts on Less <br /> n' <br /> MAXIMUM ALLOWABLE B-T-%-E LEVELS (PPM) B 50 50 50 .3 .3 X 1. NAL <br /> ample Result: SOLINE 1000 100 10 <br /> IMUM 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 teaching potential ' <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> .. 11 If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do no use table. <br /> 12 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). f <br /> V1. STAFF RECOIMIENDATION/CONCLUSIONOd an Grer,,5G ftUffca ¢63, Np`r <br /> F6Zoo PPrt-D Ih,y�40 <br /> 1- Are BTX 8 E or TPH Concentrati are; > Allowable levels Yes o W(J'S 285 J t r" <br /> 2. Recommend Site Closure FEE If Yes, Refer to Site Mitigation for Eva wat IOn <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER NAILED / <br /> AME OF - <br /> _VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 - - <br /> i <br />