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SAN JOAOUI JNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H DIVISION — <br /> I, UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE `2-Z7,--3 l-6icl <br /> NAME OF FACILITYSWEEPS CODE a"5�oC1q{ <br /> jADDRESS �� l `�-� TANK ID # - <br /> FUEL TYPE <br /> C Vj& <br /> II. GENERA SITE HISTORY <br /> *** <br /> IS permit current? Yes No Permit # - Facility Status Code Doc.Soil/GW Cont Yes No <br /> 'Number of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual <br /> III. TANK HISTORY <br /> ;Was Tank tested? Yes No Failed precision test ? Yes No If yes, give date(s) <br /> 'Was a repair made to the tank system? Yes No If yes, what was repaired? <br /> uas repair done under inspection? Yes No Were soil samples analyzed? Yes INo BTXE TPH-G 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 DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Ground Water 140 Ref/Year 003 ; Average Annual Precipitation A= 14 10-25 <br /> i <br /> On-Site Well(s) Yes No I>< Number & Type Irr 00-1 1 <br /> Pub <br /> S Score S Score S Score <br /> jDistance to Well(S) from Tank ft; 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 /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet) >100 51-100 25-50\1 <br /> (Fractures in subsurface (applies to foothills or mountain areas) None Unknown Present <br /> ';Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> IMan-Made conduits which increase vertical migration <br /> !of leachate (i.e., septic systems, water wells, ponds) f® None Unknown Present <br /> %Unique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> xxxxxx None one one <br /> i <br /> COLUMN TOTALS>>>TOTAL POINTS + _ <br /> {Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more - 48 pt 40 pts or less <br /> Na x v,►tti wry <br /> 1-_D-05 B[501 <br /> X E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 .3 1.3 1. 1. NA\3 <br /> I <br /> ;Sample Result: GASOLINE 1000 108 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPN DIESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground 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 /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> j \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 M1 cteirc <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No 1 <br /> 2. Recommend Site Closure Yes No *If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SEylfOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES 1.,...: 0 <br /> DATE REFERRED / / ; DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> U_ I J-AALO'�� <br /> EH 23 80 (UGTWKSHT)\5/90 <br />