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SAN JOAOUOUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL JH DIVISION <br />I. .= UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE( <br />NAME OF FACILITY I AS Y -(u. (SWEEPS CODE( i r, n <br />ADDRESS( a S, 1 J / h 1� 7- (I�✓ L�� CI�JJcL� ANK ID #1 %I <br />ITANK SIZEI1a&Dt)O IFUEL TYPE_ <br />II. GENERAL SITE HISTORY ,\ �•e.i <br />permit current? <br />Yes <br />IN-1 <br />No <br />(Depth to Ground water <br />Permit # <br />- <br />Average AnnuaL Precipitation <br />Facility <br />Status Code <br />10-25 <br />Doc.Soi L/GW Cont <br />YesRN-1 <br />Were soil samples analyzed? Yesl <br />No <br />nber of Tanks at <br />facility) <br />ITPH-C TPH-D Pb/EDB( <br />Age of Tanks(if <br />available)( <br />ILong-term leakage <br />Type of Tank <br />Steel <br />Fbrgl <br />ISngII <br />Dual <br />Ill. (AML HISTORY <br />Was Tank tested? IYes <br />11NO1 IREFERRED TO SITE MITIGATION FOR EVALUATION <br />IN-1 <br />Failed precision test ?IYes <br />(Depth to Ground water <br />No <br />If yes, give date(s) <br />Average AnnuaL Precipitation <br />Was a repair made to the tank system? IYesNo <br />If yes, what was repaired? <br />10-25 <br />Was repair done under inspection? iYes l <br />No <br />Were soil samples analyzed? Yesl <br />No <br />BTXE <br />ITPH-C TPH-D Pb/EDB( <br />Type of failure/discharge Icatastrophic <br />Doml <br />ILong-term leakage <br />Ioverfill <br />unknown) <br />other: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />116 <br />5 <br />6(j <br />Soil Samples Received Yesl <br />11NO1 IREFERRED TO SITE MITIGATION FOR EVALUATION <br />No <br />NO <br />(Depth to Ground water <br />CLOSURE LETTER MAILED <br />Ref /Yea <br />Average AnnuaL Precipitation <br />A=I <br />14 <br />10-25 <br />On -Site weLL(s) <br />Yes <br />No <br />Number & Type <br />Irr <br />Doml <br />Pub) <br />S <br />C <br />Score <br />10 pts <br />S <br />C <br />Score <br />9 pts <br />5 <br />C <br />Score <br />5 pis <br />Distance to Wells) from Tank ft; ft; ft <br />0 <br />if <br />0 <br />if <br />0 <br />if <br />R <br />condition <br />R <br />condition <br />R <br />condition <br />V. Site Feature - Leaching Potential Are Lysis <br />E <br />is met <br />E <br />is met <br />E <br />is met <br />Minimum Depth to groundwater from the Soil Sample (feet),20 -13 = % <br />I >700 <br />51-700 <br />I <br />25-50\1 <br />Fractures in subsurface (applies to foothills or mountain areas) <br />/ o <br />None <br />Unknown <br />(Present <br />Average Annual Precipitation (inches) <br />xxxxxxl <br /><10 <br />9 <br />110-25 <br />Ixxaaxxxl <br />26-40\2 <br />(Man -Made conduits which increase vertical migration <br />of leachate (i.e., septic systems, water wells, ponds) <br />None <br />Unknown <br />Present <br />Unique site features: Recharge area, coarse soil, nearby wells. <br />At least <br />More than <br />xxxxxx <br />None <br />/ <br />we <br />one <br />?g,z)KWa, T4_'In "er <br />/iOTALS>>>TOTAL <br />h,TU' COLUMN POINTS <br />1 <br />_� <br />S le Result. (B T X OR E) <br />RANGE OF TOTAL POINTS <br />49 pts or more <br />41 - 48 pts <br />- 40 pts or less <br />T`'AgpP" <br />I <br />13 )t- <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) <br />B <br />1 <br />T X E <br />50 501 50 <br />9 T X E <br />.3 .3 1. 1. <br />NA\3 <br />Sample Result: a <br />GASOLINE <br />1000 <br />I 100 <br />I 10 <br />H G : 1go0 <br />MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br />PH <br />DIESEL <br />10,000 <br />1000 <br />100 <br />FOOTNOTES: `*'if documented soil and/or ground water contamination is present, do not complete the leaching. 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 />\2 If precipitation is > 40 inches, score 0 points. <br />\3 Levels for BTXBE are hot applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br />VI. STAFF RECOMMENDATION/CONCLUSION -f Y __ }6 <br />1 I13 E / _ / ID <br />1, Are RTX & E or TPH Concentrations > Allowable Levels `Yes No TK # � TKA <br />2. Recommend Site Closure Yell Na 'If Yes, Refer to Site Mitigation for Evaluation % .05FPK'y i8�- of <br />&Z> _4'a /hlK All ti <br />VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR 14 <br />10 AL� <br />CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE I YES( <br />11NO1 IREFERRED TO SITE MITIGATION FOR EVALUATION <br />YES <br />NO <br />DATE REFERRED ��_ / c� / DATE <br />CLOSURE LETTER MAILED <br />WANE OF <br />EVALUATOR <br />kL_J.v✓ �V/ �.Y <br />EH 23 80 (UGTWKSHT)\5/90 <br />