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.� r1 <br /> I. SAN JOWCOUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAYHEALTH DIVISION <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE �J <br /> AME OF FACILITY <br /> WEEPS CODE 3S/ <br /> DRESS �//( Z N <br /> ANK ID tY <br /> ANK SIZE �Jl� UEL TYPE Rt�U O 9— �( i <br /> �- <br /> I1. GENERAL SITE HIS ORY <br /> Is permit current? es o ermit # *' <br /> acility Status Code ' oc-Soil/GW Con es o <br /> umber of Tanks at facility ( / ge of Tanks(if available) ype of Tank teel Fbrgl <br /> ' ngl Dua[ <br /> I11. TANK HISTORY <br /> as Tank tested? as o ailed precision test 7 es o 1f yes, give dates) <br /> Jas a repair made to the tank system? es No f yes, what was repaired? <br /> as repair done under inspection? es 40 ere soi[isamples analyzed? eso TXE PH-G PH-D b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfill nown the r: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received eso epth to Cround Water ��� of/Year i F O verage 'Annual Precipitation 4 0-25 <br /> -Site Wells) es I ✓ o } umber & T <br /> YPe 2—I rr om ub <br /> istance to Welt(s) from lank 2 t S core S core S core <br /> ft; S ft; PT ft C 0 pts C 0 pts C i pts <br /> 0. if 0 if 0 f <br /> V. R ondition R condition R ondition P <br /> Site Feature - Leaching Potential Analysis ',' '� E is met E is met E s met <br /> r <br /> inimum Depth to groundwater from the Soil Sampte (feet)6u - >100 1-100 <br /> Iris _ 25-5011 <br /> ractures in subsurface (applies to foothills or mountain areas) r` None Unknown resent <br /> verage Annuat Precipitation (inches) xxxx <10 9 10-25 KXXXXXx 25-4012 <br /> an-Made conduits which increase ve=- a <br /> tion <br /> f leachate (i.e., septic systems, ponds) None Unknown S resent- j <br /> pique site features: Recharge area, coarse soil nearby Wells. At least lore than 1 <br /> xxxxx None one ,j one <br />" ..ei�GCa.raaZia� / <br /> COLUMN TOTALS—TOTAL POINTS CU + <br /> Va le Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts dr les <br /> ES Nn <br /> 7Z)9 <br /> m MAXIMUM ALLOWABLE B-T-X-E LEVELS (PAH) 1 50 50 50 .3 3 1. 1. N L <br /> Sample Result: GASOLINE 1004 100 1p <br /> Z 3 IMUM ALLOWABLE TPH LEVELS (PPM) <br /> IESEL 10,000 1000' 100 <br /> OOTNOTES: ***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 /> 111 If depth is > 5 ft. and < 25 ft.., score'0 points. If depth ,­5 5 ft., do not use table. <br /> L If precipitation is > 40 inches, score 0 points. <br /> 13 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 87X 8 E or TPN Concentrations > Allow le Levets Yes a <br /> 2. Recomnend Site Closurees o If Yes, Referyto Site Mitigation for Evaluation <br /> VI,I. 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 1 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> -VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> �� i <br />