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SAN JOA6 COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENT*ALTH DIVISION <br /> 1• UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY � � WEEPS CODE <br /> DRESS d/i d ANK ID # <br /> TANK SIZE OU� UEL TYPE u/ <br /> 11. GENERAL SITE HISTORY <br /> RR <br /> Is permit current? es o ermit # - acility Status Code k'� oc.Soil/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) IType of Tank Leel I Fbrgl ngl I Dual <br /> 111. TANK HISTORY <br /> as Tanktested'? es o ailed precision test 7 es o If yes, give date(s) <br /> Jas a repair made to the tank system? es No f yes, what was repaired? <br /> Jas repair done under inspection? es 40 ere soil samples analyzed? es o THE PH-G PH-D b/EDB <br /> ype of failure/discharge atastrophic Long-term leakage verfill noun I lother: <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 O of/Year verage Annual Precipitation k= 4 0-25 <br /> n-Site Wells) es o umber 8 Type Irr an ub <br /> S Score S Score S Score <br /> istance to Well(s) from Tank ft; ft; ft C 10 pts C 9 pts C i pts <br /> 0 if 0 if 0 if <br /> R ocliti on R condition R ondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> ininxun Depth to groundwater from the Soil Sample (feet) >100 1-100 25-5011 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> %verage Annual Precipitation (inches) xxxx 00 9 10-25 xxxxxx 26-40L <br /> Ian-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> pique site features: Recharge area, coarse soil, nearby wells. At least lore than <br /> xxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS I-PO t 3� ♦ <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> ��At .l G� X E B T % E <br /> MAXIMUM ALLOWABLE B-T-X- VELS (PPM) 1 50 50 50 .3 .3 1. 1. NA,L3 <br /> ample Result: ASOLINE 1000 100 10 <br /> A%IMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> OOTNOTES: --*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 /> 11 If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> _\_2If precipitation is > 40 inches, score 0 points. <br /> L Levels for BT%8E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> H:91.• ¢:J COu.�' i✓2�.(� .:?Y tot. <br /> 1. Are BT% 8 E or TPH Concentrations 1>'Allowable Levels Yes o <br /> I2. Recommend Site Closure 1Y es I �40 t// ,f Yes, Refer to Site Mitigation for Evaluation <br /> VII. 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 O <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> 'VALUATOR <br /> EN 23 80 (UGTWKSHT)\5/90 <br />