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4 <br /> SAN JOACOUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTALALTH DIVISION. <br /> I: UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY SWEEPS COD£ <br /> DRESS TANK ID # - <br /> TANK SIZE UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? es o ermit # - acility Status Code oc-Soil/GW Cont es a <br /> Number of Tanks at facitity ge of Tanks(if available) i ype of Tank teel Fbrgl ngl Dual <br /> III. TANK HISTORY <br /> "3 <br /> Jas Tank,tested7 es INo ailed precision,ltest 7 es o If yes, give date(s) <br /> as a repair-Imade to the tank system? es No,i f yes, what was repaired? y <br /> Jas repair done under inspection? es No 1 ere Boit samples analyzed? es a TXE PH-GPH-D b/EDB <br /> a <br /> Type of failure/dischargeatastrophic long-term leakage verfi[L nknown ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples ?Received es IN. epth to GroiM'Water 5 of/Year g ,, verage Annual Precipitation = 4 0-25 <br /> )n-Site Wel[{'s) es 1 o umber & Type Irr an ub <br /> S Score S Score S Score <br /> istance to WeLL(s) from Tank ft; ft; _f t C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R ondition R condition R ondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) ac -5 >100 1=100 5 25-5051 <br /> Fractures in subsurface (applies to foothills orimountain areas) Q None Unknown resent <br /> i <br /> verage Annual Precipitation (inches) xxxxxx <10 9 10-25 Kxxxxxx 25-40L <br /> 4 <br /> Ian-Made conduits which increase vertical migration <br /> f leachate (:i.e., septic systems, water wells, ponds) None Unknown resent <br /> pique site features: Recharge area, coarse soil', nearby wells. At leastore than <br /> xxxx None one 5 one <br /> It <br /> rr �r <br /> COLUMN TOTALS»>TOTAL POINTS Y O + b + 6 r� <br /> 3 <br /> Sample Result!: (B T X OR E) !RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> BTX E B IT X E <br /> ?� MAXIMUM ALLOWABLE 8-.T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NAL <br /> ample Result,: ; ASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH,LEVELS (PPM) . .. I j <br /> !i TPH IESEL' 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the leaching potential <br /> analysis. (i.e., site,iis currently on UGT Contamination List for soil or ground water.) <br /> 1 If depth is > 5 ft. and < 25'ift.; score 0 points. If depth <=5 ft., do not use table. <br /> 12 If precipitation is > 40 inches, score 0 points. <br /> 3 Levels for BTX&E are not applicable at'a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION VuE <br /> 1. Are BTX:& £ or TAH 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 /> DNCUR <br /> WITH STAFF RECOMMENDATION FOR CLOSURE E5 Q EFERRED TO SITE MITIGATION FOR EVALUATION ES O <br /> 3 <br /> ATE REFERRED / / ATE CLOSURE.LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHTA5/90 <br />