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SAN JOA10GOUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAALTH DIVISION <br /> 1' UUGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> AME Of FACILITY bo( (zi/. p�z.-h(�,� ATE <br /> DORE SS EEPS CODE I'b tic)Q <br /> 20 5 erIc <br /> � <br /> CONK SIZE �fn� ANK ID p�DDO �aY UEL TYPE DItspet`15e✓ <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? es o ** <br /> ermit q acility Status Codeoc.Soil/GW Cont es io <br /> umber of Tanks at facility ge of Tanks(it available) <br /> ype of Tank reel rgl ngl Dual <br /> III. TANK HISTORY <br /> as Tank tested? as o ailed precision test ? as o if yes, give dates) <br /> as a repair made to the tank system? as No f yes, what was repaired? <br /> as repair done under inspecti on7 es o ere soil samples analyzed? es 7o TXE PH•G PH-D b/ED6 <br /> ype of failure/discharge atastrophic long-term leakage verfill nknown ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Oil Samples Received as o epth to Ground Water 30 of/Year C%; verage Annual Precipitation = 4 10-25 <br /> n-Site Well(s> as o umber 8 Type Irr om ub <br /> istance to Wells) from TankS core S core S core <br /> ft; ft; ft C 0 pts C pts C pts <br /> 0 f 0 if 0 f <br /> Site Feature - Leaching Potential Analysis R ondition R ondition R ondition <br /> E is met E is met E 's met <br /> ininlum Depth to groundwater from the Soil Sample (feet)3DI 22 >100 <br /> 1-100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) <br /> None Unknown resent <br /> verage Annual Precipitation (inches) xxxxx <10 <br /> 9 10.25 xxxxxx 26.40\2 <br /> on-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) <br /> None I Unknown resent <br /> lnique site features: Recharge area, coarse soil, nearby wells: At least <br /> 9 ore than <br /> one <br /> xxxxx None one <br /> COLUMN TOTALS>»TOTAL POINTS + G 3q <br /> ample Result: (B TXX\(OR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or less <br /> 2� m (LQ MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) B 50 50 50 .3 .3 1. <br /> "ample Result: <br /> AXIMUM ALLOWABLE TPH LEVELS (ppN) ASOLINE 1000 100 10 <br /> 5q' TPH IESEL 10,000 1000 <br /> 100 <br /> OOTNOTES: ***)f documented soil and/or ground water contamination is present, do not complete the leaching potential <br /> analysis. (i <br /> \1 If depth -a-, site is currently on UGT Contamination List for soil or ground eater.) <br /> 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 BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> plSPef)Ser qf•fc-r <br /> 1. Are BTX S E or TPH Concentrations > Allowable Levels Yes o 3•�•qO re-eXcuvai7on gt{Cnt <br /> 2. RCcemmend Site Closure as o If Yes, Refer to Site Mitigation for Evaluation MOO; I�TE D.L_' 75Z)ffb. <br /> Vil. 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 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> .VALUATOR (� -7 <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />