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SAN JOAI COUNa.iPUBLIC HEALTH SERVICES/ENVIRONMENT, ALTHJISION DATE <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATI <br /> 1. <br /> NAME OF FACILITY II,y ? <br /> l SWEEPS CODE <br /> TANK 1D # <br /> ADDRESS �/ <br /> TANK SIZE f/ FUEL TYPE <br /> II. GENERAL SITE HISTORY <br /> Is permit current? Yes No Permit # - Facility Status Code DOC.$OI l/GN Cont Y <br /> Nf <br /> es No <br /> Number oTanks at <br /> Age of Tanks(if available) Type of Tank Steel FbrgL Sngl Dual <br /> facility <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test ? Yes No If yes, give date(s) <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? <br /> Was repair done under inspection? Yes No Were soil samples analyzed? Yes No BTXE TPH-G TPH-D Pb/EDB <br /> Type of failure/discharge catastrophic long-term Leakage overfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Ground Nater Ref/Year <br /> Average Annual Precipitation A= 14 10-25 <br /> On-Site WeLL(S) Yes No Number & Type Irr Dan Pub <br /> S Score S Score <br /> Score 5 <br /> 5 pts <br /> Distance to Wel l(s) from Tank ft; ft; ft C 10 pts C 9 pts C <br /> 0 if 0 if 0 if <br /> R condition R condition R is met V. Site Feature - Leeching Potential Analysis <br /> E is met E is met E <br /> Minimum Depth to groundwater from the Soil Sample (feet) <br /> >100 51-100 25-50\1 <br /> A None Unknown Present <br /> Fractures in subsurface (applies to foothills or mountain areas) (/ <br /> Average Annual Precipitation (inches) <br /> xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration None Unknown Present <br /> of Leachate (i.e., septic systems, water wells, ponds) <br /> /] At Least More than <br /> Unique site features: Recharge area, coarse soil, nearby wells. xxxxxx Nora _I one one <br /> P t COLUMN TOTALS>>>TOTAL POINTS <br /> = C <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> B T X E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. MI <br /> GASOLINE 1000 1 10 <br /> Sample Result: <br /> MAXIMUM ALLOWABLE TPN LEVELS (PPM) DIESEL 10,000 700 100 <br /> TPH <br /> FOOTNOTES: <br /> -**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 fionotusetable. <br /> st drrSoil rue� water. <br /> \1 if depth is > 5 ft. and < 25 ft., score 0 points. If depth <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 /////q�� <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels "Yes No /�Qn YI U ^ <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 v" <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />