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SAN JOS�f <br /> _ V COUNTY PUBLIC";HEALTH SERVICES/ENVIRONMENIP �EALTH DIVISION <br /> i. <br /> :r UGST WORKSHEET FOR SITE CLOSURE EVALUAT,ID�! ATE Re{I <br /> AME OF FACILITYt�� "l C WEEPS CODE Z f <br /> DRESS V, ANKIJP N <br /> ANK 5I2E SU�. IIEL TYPE r L <br /> L� <br /> Z (J�;II. GENERAL SITE HISTORYi <br /> Is permit current? es 0 ermit N - acuity Status Code! D q oc.Soil/GW Cont e a <br /> umber of Tanks at facility ge of Tanks(if'avaitable) NtC J <br /> U ype of Tank teeE Fbrgl" ngl Duai IL <br /> III. TANK HISTORY <br /> Jas Tank tested? es I o Vjaii.ed precision test ? es, o if yes,. give <br /> Jos a repair made to the tank system? es Nof <br /> yes; what was repaired? <br /> Jos repair done under inspection1es" o era soit "samples analyxed7 es o TXE PH-G PH-D b/EDB <br /> ype of failure/discharge atastrophic Long-term leakage verfiLL nownPF <br /> ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR <br /> LEACHING POTENTIAL ANALYSIS) <br /> ) <br /> oi! Samples Received es a epth to Ground Water of/Tear verage Annual Precipitation <br /> -Site WeLI(s) es o umber & Type t Irr" am ub <br /> S core S S care S core <br /> ?stance to Weil(s) from Tank ft; ft- GIR " . ft C 0 pts C PCs C PCs <br /> 0 if 0 if 0 f <br /> W. R ondition R condition R ondition <br /> Site Feature - Leaching Potential Analysis i. " E is met E is met E s <br /> Met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-10025-501 <br /> D. <br /> ractures in subsurface (applies to foothilts or mountain areas) 0 None Unknown PIresent <br /> verage Annual Precipitation (inches) KXXXXX <70 9 10-25 zxxxxz 26-4012 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i-e., septic systems, water wells, ponds) "; None Unknown J5 resent, <br /> pique site features: Recharge area, coarse soil, nearby wells. At least ore than <br /> I <br /> xxxx None one one ' <br /> COLUMN TOTALS>>>TOTAL POINTS �(� j S <br /> P. <br /> ample Result: (B T X OR E) RANGEOF TOTAL POINTS 9 pts or more ;;5 41 "- 48 pts 40`,:pts or less <br /> FS-1 22' <br /> r-thyrlboizem `✓-Pfb B T x E B T X E <br /> FKAXIMUMALLOWABLE B-T-X-E LEVELS (PPM) 1 150 150 150 3 .3 1. 1. NAL <br /> ample Result: SOLINE 1000 100 10 <br /> IMUN ALLOWABLE.TPH LEVELS (PPM) <br /> TPH j IESEL 10,000 1000 100 <br /> OOTNOTES: ***If documented soil and/or ground water contamination -isresent do not complete amplete the Leachingpotential ' <br /> analysis. (i.e., site is currentty,on UGT Contamination List for soil or ground water.) t <br /> L If depth is > 5 ft. and < 25 ft., score 0 points. If depth < 5 ft do not use table. . b <br /> %2 If precipitation is > 40 inches, score O�points. <br /> L Levels for .BTX&E are not applicable at a TPH concentration of 10 ppm"(gasoLine) oe 100 ppm (diesel), <br /> VI. STAFF RECOMMENDATION/CONCLUSION lit aridGrEri5C =0-3,. <br /> F5l PPm <br /> 7. Are BTX & E or TP" Concentrations > A!lowabie Levels Yes <br /> 2• Recommend Site Closure es0 If Yes, Refer 6-Site Mitigation for Evacuation <br /> VI1. 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 O <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR ! <br /> . EH 23 80 (UGTWKSHT)\5/90 <br />