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SAN JOAN."COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL hi LTH DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE Cf <br /> AME OF FACILITY WEEPS CODE J <br /> i <br /> DRESS D D UTANK ID.# %23 -- J <br /> ANK SIZE �DD UEL TY E <br /> 1I. GENERAL SITE HISTORY <br /> ** <br /> L 'ol��t <br /> current? es o ermit # acuity Status Code oc.Soil/GW Cont es or Tanks at facility ge of Tanks(if available) ype of Tank feel Fbrgt ngl Dual <br /> I11. TANK HISTORY <br /> as Tank tested? esX o ailed precision test 7 es o X:,.If yes, give date(s) <br /> as a repair made to the tank system? Yes No 11f yes, what was repaired? <br /> Jas repair done under inspection? es 40 ere soil samples analyzed? es o TXE PH PH-D b/EDB <br /> h- <br /> ype of failure/discharge atastrophic long-term leakage verfill nknown I lothe'r; <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA�FOR LEACHING POTENTIAL ANALYSIS) ��! <br /> oil Samples Received es X o I epth to Ground Water of/Year ; verage Annual .Precipitation = 4 0-25 <br /> i <br /> -Site Wells) es o umber & Type 1rr. an ub <br /> S core S core 5 core <br /> istance to Well(S) from Tank ft; ft; ft C 0 pts' C pts C pts <br /> 0;. if 0 cif 0 if <br /> R. rondition 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) >100 1-1005 25-501 <br /> Fractures in subsurface (applies to foothills or mountain areas) Q None Unknown resent <br /> verage Annual Precipitation (inches) Kxkxxx <10 9 10-25 KXXXXXX 26-402 <br /> an-Made conduits which increase vertical migration , p <br /> Df leachate (i.e., septic systems, water wells, ponds) "`'t None Unknown 15 resent <br /> nique site features: Recharge area, coarse soil,nnearby wet S. At ,least ore than <br /> �t1-� 0jxxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS <br /> J I <br /> ampte 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 BJT X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 5Q .3 .3 1. 1. NAL3 <br /> Sample Result: ASOLINE i 1000 100 10 <br /> ril D (p I Q r"" AXIMUM ALLOWABLE TPH LEVELS (PPM) „ <br /> TPH IESEL 10,000 1000 100 <br /> OOTNOTE$: ***If documented soil and/or gr'ound 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 not use table. <br /> y If precipitation is > 40 inches, score 0 points, <br /> 13 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> Iti <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes <br /> 2. Recommend Site Closure 1Y <br /> es o 1f Yes. Refer to Site Mitigation for Evaluation � �41 RD <br /> V11. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIORN OL <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE tESt 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> j VALUATOR <br />' EH 23 80 (UGTWKSHT)\5/90 <br />