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SAN JOAOU�1!'l7OUNTY PUBLIC HEALTH SERWI CES/ENVIRONMENTAL��LTH DIVISION DATE �. <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> 1• A ,� SWEEPS CODE f, <br /> NAME OF FACILITY l:N TANK ID # \ <br /> ADDRESS S U l"• k�4l <br /> TANK SIZE FUEL TYPE <br /> •.. <br /> II. GENERAL SITE HISTORY <br /> Is permit current? Yes No <br /> Permit k - Facility Status Code Doc.Soil/GW Cont Yes No <br /> Number of Tanks at facility <br /> Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual <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 TPN-G iPH-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 Water <br /> Ref/Year ; Average Annual Precipitation A: 14 10-25 <br /> On-Site Wells) Yes No Number 8 Type Irr Dom PubS Score S Score 5 Score <br /> Ft- ft C 10 pts C 9 pts C 5 pts <br /> Distance to WeIL(s) from Tank ft; 0 if 0 if 0 if <br /> R condition R condition R condition <br /> E is met E is met E is met <br /> V. Site Feature - Leaching Potential Analysis is met 25-50\1 <br /> >100 <br /> Minimum Depth to groundwater from the Soil Sample (feet) <br /> None 1 1 Unknown Present <br /> Fractures in subsurface (applies to foothills or mAuntain areas) <br /> xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> Average Annual Precipitation (inches) <br /> Man-Made conduits which increase vertical migration None Unknown Present <br /> of leachate (i.e., septic system, water wells, ponds) At least More than <br /> Unique site features: Recharge area, coarse soil, nearby wells. xxxxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS J <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> ^ .r^ B T X E B T X E <br /> Q,L. MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> GASOLINE 1000 100 10 <br /> Sample Result-. DIESEL 10,000 1000 <br /> TPN <br /> FOOTNOTES: <br /> ***If doc mented 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. [f depth <=5 ft., do notusetable. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTXBE ere not applicable at a TPX concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> i. Are BTX d E or TPX Concentrati > Allowable Levels *Yes No <br /> 2. Recommend Site Closure Yes No *If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMP L TED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES 0 REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR ' <br /> EX 23 80 (UGTWKSHT)\5/90 <br />