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SAN JOAta,. COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENT.L HEALTH DIVISION <br /> 1' UGST WORKSHEET FOR SITE CLOSURE EVALUATION _ <br /> ATE Q 7_ <br /> AME Of FACILITY �_ / _� —J G�a +� C <br /> /J/ WEEPS CODE <br /> DRESS a 70TANK IO <br /> / ��011 a <br /> ANK SIZE 'i <br /> -/ 7 7� <br /> LZ_ <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? es o ermit # acilit Status Code C ** <br /> Y oc.Soil/GW Cont es o <br /> umber of Tanks at facility Eg- ofnks(if available) <br /> �7 ype of Tank teal FbrgI ngl Dual <br /> Ill. TANK HISTORY <br /> as Tank tested? es o ailed precision test ? es o If yes, give dates) <br /> as a repair made to the tank system? es No f / <br /> yes, what was repaired? <br /> as repair done under inspection? es o l/ ere soil samples 4halyze( es o TXE PH G PH-D v b/EDB <br /> ype of failure/discharge atastrophic Long-term leakage verfill nknown they: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es o epth to Ground eater of/Year <br /> • � verage Annual Precipitation = 4 0-25 <br /> -Site WeLI(S) es o umber & Type Irr om ub <br /> istance to WellS core S core S core <br /> Wells) from Tank ft; ft; ft C 10 pts C pts Cis <br /> 0 if <br /> 0 if 0 if p <br /> R :ondition R ondition R ondition <br /> Site Feature - Leaching Potential Analysis J�—1�p - y E is met E is met <br /> E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) > <br /> 100 1-100 25-50,L <br /> ractures in subsurface (applies to foothills or mountain areas) G None <br /> Unknown resent <br /> verage Annual Precipitation (inches) xxxxx <10 9 10 25 xxxxxx 26 40� <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None 1 <br /> Unknown resent <br /> nique site features: Recharge area, coarse soil, nearby wells. <br /> G At least ore than <br /> xxxx None ' one one <br /> COLUMN TOTALS»>TOTAL POINTS ' (> 1W <br /> + 4 (J <br /> ample Result: (8 T X OR E) RANGE OF TOTAL POINTS 9 pts or more Z 41 - 48 pt 40 pts or less <br /> ----G I 1 B T X E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 5 _ .3 .3 1. 1. NAL <br /> ample Result: GASOLINE 1000 100 10 <br /> G l UAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> ' TPH IESEL 10,000 1000 100 <br /> OOTNOTES: ***If documented soil and/or ground water contamination is present, do`ctot complete the leaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or,gtound water.) <br /> , 1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do no[ase table. <br /> !f precipitation is > 40 inches, score 0 points. <br /> L Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPM Concentrations > Allowable Levels Yes o'o <br /> �r , d r Q c'o <br /> 2. Recommend Site Closure es o ' If Yes, Refer to Site Mitigation for Evaluation D <br /> V11. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION fES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> =VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />