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SAN JOAOUI NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H DIVISION I t <br /> I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION IDATEI <br /> `NAME OF FACILITY <br /> SWEEPS CODE <br /> JADORESSI TANK IDI <br /> :TANK SIZE( (FUEL TYPE( <br /> II. GENERAL SITE HISTORY _ <br /> Is permit current? Yes! !No (Permit #I - (Facility Status Codel Doc.Soil/GW Cont'Yesl No <br /> ;Number of Tanks at facility Age of Tanks(if available)( Type of Tank Steel Fbrgli ISngII Dual <br /> II:. TANK HISTORY <br /> (Was Tank tested?!Yesl jNol (Failed precision test ?!Yes) 'NoI lIf yes, give date(s) <br /> !Was a repair made to the tank system? Yes NoI IIf yes, what was repaired?I <br /> luras repair done under inspection?)Yes' INo) Were soil samples analyzed?!Yes `Nal BTXEI (TPH-GI TPH-D Pb/EDB( ' <br /> 'Type of failure/discharge) catastrophic) (long-term leakage) (overfill) unknown! +other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE D-eTAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> ;Soil Samples Received Yes! INoI (Depth to Ground Water 'Ref/Year )Average Annual Precipitation A= 14 10-25 <br /> jOn-Site Well(s)fYes INo INunber & Typel Irrf Domj (Pub! <br /> S Score S Score S Score <br /> )Distance to WeIL(s) from Tank ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R condition R condition R condition <br /> IV. Site Feature - Leaching Potential Analysis E !is met E is met E - -- is met <br /> i <br /> Minimum Depth to groundwater from the Soil Sample (feet) I >100 l 151-100 l l 25-50\1 <br /> i <br /> ractures in subsurface (applies to foothills or mountain areas) I None l Unknown I (Present ! <br /> iAverage Annual Precipitation (inches) �xxxxxxl <10 1 9 110-25 Ixxxxxxx 26-40\2 <br /> ;Man-Made conduits which increase vertical migration <br /> iof leachate (i.e., septic systems, water wells, ponds) ( None I Unknown I Present <br /> :Unique site features: Recharge area, coarse soil, nearby wells. I I I At Least) (More than <br /> j xxxxxx None one one <br /> t <br /> COLUMN TOTALS>>>TOTAL POINTS + <br /> f I <br /> :Sample Result: (B T X OR E) RANGE OF TOTAL POINTS49 pts or more i 41 - 4$ pts l 40 pts or less <br /> B T X E B X EMAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) i 50` 50 50 .3 I.T <br /> 3 ( 1.I 1. ! NA\3 <br /> (Sample Result: GASOLINE 1000 I 100 I 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> ! TPH DIESEL 10,000 I 1000 I 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the leaching potential <br /> analysis. (i.e., site is currently on UGT 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 BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes: NoI <br /> 2. Recommend Site ClosurelYesi No <br /> If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSUREIYES INOI !REFERRED TO SITE MITIGATION FOR EVALUATIONIYES1 !NO! <br /> DATE REFERREDI I ;DATE CLOSURE LETTER MAILEDI I <br /> NAME OF <br /> EVALUATOR( <br /> EH 23 80 (UGTWKSHT)\5/90 <br />