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♦ SAN JOAOOUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAALTH DIVISION G <br /> 1' UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE l 7 / <br /> COO <br /> WEEPS CODE <br /> � s ANK ID # `To, <br /> UEL TYPE IeSe._� iF15 l <br /> 11. GENERAL SITE HISTORY Y2NnDJ� g <br /> .. <br /> s permit current? es o ermit # acility Status Code oc.Soil/GW Cont es !o <br /> umber of tanks at facility ge of Tanks(if available) ype of Tank teel Fbrgl ngl Dual <br /> III. TANK HISTORY <br /> NM— <br /> IV. <br /> as o ailed precision test ? es o If yes, givejdate(s)to the tank system? es No f yes, what was repaired?nder inspection? es o ere soil lPH-G PH-D b/EDB <br /> ischarge atast <br /> IV• REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> soil Samples Received es o epth to Ground Water of/Year verage Annual Precipitation = 4 10.25 <br /> •Site Wells) es o umber & Type Irr Om ub <br /> istance to Wells) from Tankft; S core S core S core <br /> ft; ft C 0 pts C pts C pts <br /> . 0 if 0 if 0 'f <br /> Site feature - Leaching Potential Analysis R onditi on R ondition R onditionE is met E is met E s met <br /> inimum Depth to groundwater from the Soil Sample feet <br /> aP ( ) 30-g_22 >100 1.100 25•5o\1 <br /> Factures in subsurface (applies to foothills or mountain areas) �Q None <br /> Unknown resent <br /> verage Annual Precipitation (inches) xxxxx <10 9 <br /> 10-25 xxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration Q <br /> f leachate (i.e., septic systems, water wells, ponds) None 1 <br /> Unknown resent <br /> Inique site features: Recharge area, coarse soil, nearby wells. <br /> At least ore than <br /> xxxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS 11) O <br /> 'ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or less <br /> -`fVPf' r � •PPbX B T X E 8 T % E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> -ample Result: ASOLINE 1000 100 10 <br /> DMA AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH IE SEL 10,000 1000 100 <br /> OOTNOTES: ***If documented soil and/or ground water contamination isresent, do not complete the Leachingpotential <br /> analysis. (i.e., site is currently on UST 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 /> V1. STAFF RECOMMENDATION/CONCLUSION SQ)>1�1n westZ p�c� <br /> 1. Are BTX 8 E or TPN Concentrations > Allowable Levels Yes o ©fVl.k r¢.mOt1� �•p• Its <br /> 2. Recommend site Closure es o If Yes, Refer to Site Mitigation for Evaluation Nck: OC) w� GlM[a SIS <br /> Vfl. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR l <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE 'ES '0 EFERRED TO SITE MITIGATION FOR EVALUATION ES JO <br /> AME OF <br /> LATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> may) �y <br /> :VALUATOR 7 <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />