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SAN JOAOUTANTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H16H DIVISION p <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE �0 — <br /> AME OF FACILITY "Sl ll f Q9y(� � 1 rN WEEPS CODE p <br /> DDRESS a -t�/x Q C ANK ID # itL U I <br /> TANK SIZE Qo'o UEL TYPE 1,QSO <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? ks o ermit # acility Status Code oc.Soil/GW Cont es Jo <br /> umber of Tanks at facility ge of Tanks(if available) IType of Tank IS teel Fbrgl I 13n9t Dual <br /> Ill. TANK HISTORY <br /> as Tank tested? es o ailed precision test ? if <br /> es o If yes, give date(s) <br /> as a repair made to the tank system? es No 11f yes, what was repaired? <br /> as repair done under inspection? es o ere soil samples analyzed? es I V'�Jo TXE PH-G PH-D b/EDB <br /> Type 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 /> soil Samples Received es o epth to Ground Water of/Year t verage Annual Precipitation 4 10-25 <br /> n-Site Well(s) es o �- umber & Type Irr om ub <br /> S core S core S core <br /> istance to Well(s> from Tank ft; ft; ft C 0 pts C pts C pts <br /> 0 if 0 if 0 'f <br /> R ondition R ondition R ondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E 's met <br /> inimum Depth to groundwater from the Soil Sample (feet) �� :il >100 1.100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) xxxxx <10 9 10-25 xxxxxx 26-40\2 <br /> nn-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) ' �� None Unknown resent <br /> lnique site features: Recharge area, coarse soil, nearby Wells. q At Least ore than <br /> xxxxx None I one one <br /> COLUMN TOTALS>>>TOTAL POINTS d-U <br /> ample Result: (Bo X OR ) RANGE OF TOTAL POINTS9 pts or more 41 48 pts 40 pts or less <br /> W- '•`N P'� BT X E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA%3 <br /> Sample Result: ASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> JVP 010A&TPH IDIESEL 1 10,000 1000 100 <br /> OOTNOTES: ***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 BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION 1 &L <br /> 1, Are BTX 8 E or TPH Concentrations > Allowable Levels <br /> 2. Recommend Site Closure eso If Yes, Refer to Site Mitigation for Evaluation <br /> Vtl. REVIEW EVALUATION • TO BE COMPLETED BY A SUPERVISOR/SENIOR - j <br /> ,ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUA ION ES <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> :VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 ` <br />