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SAN JOAOU OUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL .TH DIVISION <br />I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION" DATE( ` _ "1 4 <br />NAME OF FACILITY�1 I LO A ISWE_PS CODE �11 <br />ADDRESS / L 3, 1^ n (/(., / ) ANK ID #I ''�- <br />ITANK SIZEI 45 )C) IFUEL TYPE( <br />11. GENERAL SITE HISTORY w <br />Is permit current?( <br />Yes <br />No <br />No <br />Permit # <br />- <br />Facility Status Code <br />/ Doc.Soil/GW <br />Cant <br />Yes <br />No <br />Number & Type <br />Number of Tanks at facility <br />.) <br />Age of Tanks(if available)I <br />1 <br />/ 3 ,,IType <br />of Tank <br />St/eel <br />IFbrgl <br />S <br />C <br />0 <br />R <br />= <br />SngL <br />Dual <br />catastrophic <br />III. TANK HISTORY U <br />Was Tank tested? <br />Yes <br />No <br />Failed precision test ?1Yes <br />IDepth to Ground Water Ref/Year <br />Na <br />If yes, give date(s) <br />14 <br />Was a repair made to the tank system Yes <br />No <br />IIf yes, what was repaired? <br />Number & Type <br />Was repair done under inspection? iYes 1 <br />NoI <br />Dom <br />Were soil samples analyzed? Yes (NoI <br />Pub1 <br />BTXE TPH-G TPN -D <br />Pb/EDB <br />S <br />C <br />0 <br />R <br />= <br />Type of failure/discharge <br />S <br />C <br />0 <br />R <br />E <br />catastrophic <br />Distance to Wells) from Tank ft; ft; £t <br />(long-term leakage <br />overfill <br />Minimum Depth to groundwater from the Soil Sample (feet) <br />unknown <br />I >100 <br />(other: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />Soil Samples Received <br />Yes <br />No <br />IDepth to Ground Water Ref/Year <br />IAverage Annual Precipitation <br />A= <br />14 <br />10-25 <br />On -Site Well(s) <br />Yes <br />NoI <br />Number & Type <br />Ilrr <br />Dom <br />Pub1 <br />S <br />C <br />0 <br />R <br />E <br />Score <br />10 pts <br />if <br />condition <br />is met <br />S <br />C <br />0 <br />R <br />= <br />Score <br />9 pts <br />if <br />condition <br />is met <br />S <br />C <br />0 <br />R <br />E <br />Score <br />5 pts <br />if <br />condition <br />is met <br />Distance to Wells) from Tank ft; ft; £t <br />V. Site Feature - Leaching Potential Analysis — / 3 _ <br />Minimum Depth to groundwater from the Soil Sample (feet) <br />I >100 <br />151-100 <br />I %1 <br />v <br />25-50\1 <br />Fractures in subsurface (applies to foothills or mountain areas) <br />h �) <br />None <br />1 <br />Unknown <br />(Present <br />Average Annual Precipitation (inches) <br />xxxxxxl <br />00 <br />9 <br />110-25 <br />xxxxxxxl <br />26-40\2 <br />(Man -Made conduits which increase vertical migration <br />of leachate (i.e., septic systems, water wells, ponds) <br />U <br />None <br />Unknown <br />Present <br />Unique site features: Recharge area, coarse soil, nearby wells. <br />xxxxxx <br />More <br />q <br />At least <br />one <br />More than <br />one <br />g /! E-/_- <br />COLUMN TQTF—t!tTOTAL POINTS _ <br />O <br />- <br />' <br />- <br />�? <br />Sa�mlple Re�su}lt: (B T X OR E) <br />RANGE OF TOTAL POINTS <br />49 pts or more <br />I 41 - 48 pts <br />40 pts or less <br />MAXIMAL ALLOWABLE B -T -X -E LEVELS (PPM) <br />1 <br />T X I E <br />50 501 50 <br />B T X <br />.3 .3 1. <br />E <br />1. <br />NA\3 <br />Sample Result: 1 II ; ) <br />/`� TPX Y <br />�IMUM ALLOWABLE TPH LEVELS (PPM) <br />GASOLINE <br />1000 1 <br />100 <br />10 <br />DIESEL <br />10,000 <br />1000 <br />100 <br />FOOTNOTES: —If documented soil and/or ground water contamination is present, do not conipt ete the-t� ential <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 BTX&E are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br />VI. STAFF RECOMMENDATION/CONCLUSION <br />1. Are BTX & E or TPN Concentrations > Allowable Levels -yes No <br />2. Recommend Site Closure Yes No -If 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 YES NOI IREFERRED TO SITE MITIGATION FOR EVALUATIONIYESI 1N01 <br />DATE REFERRED DATE CLOSURE LETTER MAILED <br />NAME OF <br />EVALUATOR <br />EN 23 80 (UGTWKSHT)\5/90 <br />