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SAN JOAOUIkl..SJNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HL-f.H DIVISION <br /> I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE y 1$ <br /> AME OF FACILITY <br /> rJ ) S WEEPS CODE 2dU 4/ <br /> DRESS 31Z T E' YP IYI GI7-�- ANK ID M <br /> ANK SIZE C G7-)� UEL TYPE (.111*F' <br /> 11. GENERAL SI7E HISTORY <br /> •s <br /> Is permit current? es I o ermit Y - acility Status Code oc.Soi l/GW Cant es o <br /> umber of Tants at facility ge of Tanks(if available) ype of Tank ISLeel Fbrgl ngl I Dual <br /> 111. TANK HISTORY <br /> Jas Tank tested? es IFailed precision test 7 es I iIo If yes, give date(s) <br /> Jos a repair made to the tank system? es No 1 11f yes, what was repaired] <br /> Jas repair done under inspection] es o ere soil samples analyzed) es o TXE I PH-G I PH-O I b/EDB <br /> Type of failure/discharge atastrophic long-tern leakage verfill noun I iDther: <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 itof/Year verage Annual Precipitation 4 0-25 <br /> -Site Wett(s) es o umber 8 Type Irr ton I ub <br /> 5 Score S Score 5 Score <br /> istance to Well(S) from Tank ft; ft; ft C 10. pts C 9 pts C5 pts <br /> 0 if O if 0 if <br /> R ondition R candition R zonclition <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) >100 1.100 ,J 25.50)1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) Kxxxxx 00 9 10-25 xxxxxx 26-40,\2 <br /> an-Made conduits which increase vertical migration Q <br /> f leachate (i.e., septic systems, water wells, ponds) None I Unknown resent <br /> pique site features: Recharge area, coarse soil, nearby wells. At least 40re than <br /> xxxx None / one one <br /> COLUMN TOTALS»>TOTAL POINTS t <br /> Simple Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> GZx O ,u Al MAXI MU( ALLOWABLE B-T-X-E LEVELS (PPM) 9 50 50 50 .3 .3 1. 1. NAL <br /> Sample Result: SOLINE 1000 100 10 <br /> ,MUM ALLOWABLE TPN LEVELS (PPM) <br /> /xtCL [ TPN IESEL 10,000 1000 100 <br /> OOTNOTE$: ===If documented soil and/or ground water contamination is present, do not complete the leaching potential <br /> are lysis. (i.e., site is currently on UGT Contanina tion 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 /> L If precipitation is > 40 inches, score 0 points. <br /> M Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION , <br /> 1. Are BTX 6 E or TPH Concentratlots > Allowable Levels Yes o <br /> l2. Recommend Site Closure I es PTO o I Ir if Yes, Refer to Site Mitigati an for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/ ION <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 /> HE 0 <br /> F <br /> OT <br /> EH 23 80 (UGTWKSHT)\5/90 <br />