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SAN IOAOU�,,OUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL`�.TH DIVISION <br /> I• UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE —/ <br /> NAME OF FACILITY U"r !� SWEEPS CODE (� <br /> ADDRESS -3T' .� TANK ID # q- 610 ZL— <br /> TANK SIZE FUEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? Yes Na 1XI <br /> Permit # - Facility Status Code ! I Doc.Soi L/GW Cont fyes INa <br /> INumber of Tanks at facility) IAge of Tanks(if available)I (Type of Tank Steel r911 I <br /> Sngl Dual <br /> 1I1. TANK HISTORY <br /> Was Tank tested? Yes INC I A <br /> 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-0 Pb/EDB <br /> Type of failure/discharge catastrophic long-term leakage overfill Unknown other: 'C ._ J�� 1/ <br /> [V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS ) <br /> Soil Samples Received Yes No Depth to Ground Waterto I Ref/Year Average Annual PracipitationlA- 14 10-25 <br /> On-Site Wells) Yes No Number 3 Type ^ Dam Pub <br /> S Store S Scare S Score <br /> Distance to Wells) from Tank �ft; ft; ft C 10 pts C 9 Pts C 5 pts <br /> 0 if 0 if 0 if <br /> R condition R condition R condition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet) LJ-®.-- >100 151-100 125-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None I Unknown Present <br /> Average Annual Precipitation (inches) XXXXXX <10 97 10-25 XXXXXXX 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) None Unknwn Present <br /> Unique site features: Recharge area, coarse sail, nearby wells. At least More than <br /> X)txXX% None one one <br /> COLUMN TOTALS>>>TOTAL POINTS / ® 5 o 1 <br /> aa <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or mor 41 - 48 pts 40 pts or Less <br /> B T % E B T X E <br /> MAXIMIM ALLOWABLE R-T-%-E LEVELS (PPM) i 50 50 50 - .3 .3 1. 1. NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPN LEVELS (PPM) <br /> TPH DIESEL 10,0001000 100 <br /> FOOTNOTES: —If documented soil and/or ground water centaminati on is Present, eachinq 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 STXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 3 E or TPN Concentrations > Allowable Levels -Yes No <br /> 2. Recommend Site Closure)Yes) INQ �'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 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 />