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SAN JOAWIIT COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION C? ATE 2 y' <br /> AME OF FACILITY ISWEEPS CODE <br /> ODRESS Q q IrANK ID # <br /> ANK SIZE 0 UEL TYPE r <br /> 11. GENERAL SITE TOR <br /> la permit current? os 0 ermit # acility Status Code oc.Soil/GW Cont es o <br /> umber of Tanks at facility Be of Tanks(if available) —[Type of Tank test Fbrgl n9l L Dual <br /> 111. TANK HISTORY <br /> as Tank tested? es I IHOI ailed precision test 7 as o If yes, give date(s) <br /> as a repair made to the tank system? IYes No f yes, what was repaired7 <br /> ns repair done under Inspection? es o ere soil somples analysed? es to iKE PN-G PH-D b/EDD <br /> type of failure/discharge atastrophic long-term leakage verfilL nknown 1 10ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received Ifes o epth to Ground Water LS It of/Year verage Annual Precipitation 4 10-25 <br /> q✓ -Site wet[($) as o umber 8 Type Irr Lm <br /> ub <br /> I` S Score S Score S core <br /> istance to Wells) from Tank ft; ft; ft C 0 pts C pts C pts <br /> 0 if 0 if 0 'f <br /> R condition It condition R ondition <br /> 1. Site Feature - Leaching Potential Analysis E is met E is met E 's met <br /> inimmm Depth to groundwater from the Soil Sample (feet) >100 1-100 25.50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) xxxxxx <10 9 10-25 KXXxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> Inique site features: Recharge area, coarse soil, nearby wells. 9 At least 4ore than <br /> xxxxx None ! one one <br /> COLUMN TOTALS>»TOTAL POINTS D + .27 + ` <br /> ample Result: (B T % OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts LO 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. NA\3 <br /> Sample Result: ASOLINE1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL E.0,000 1000 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 <e5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTXBE are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1, Are BTX 8 E or TPH Concentrations > Allowable Levels Yes I IN01 <br /> 2. Recommend Site Closure Ires o If Yes, Refer to Site Mitigation for Evacuation <br /> VII. REVIEW EVALUATION - TO BE C014PLETED BY A SUPERVISOR/SENIOR <br /> .ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES I 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />