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SAN JOAOUINdJPmKTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEaaf DIVISION <br />1• UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE �9 q <br />NAME OF FACILITY 05143-7z) <br />5vkor _ SWEEPS CODE <br />ADDRESS TANK ID # 7 - 7.��� _ O <br />TANK SIZE ,TO X Z FUEL TYPE � `-�/V <br />11. GENERAL SITE HISTORY <br />is permit current? Yes No Permit # - Facility Status Code Doc -Soi L/GW Cont Yes No <br />Number of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl SngL Duet <br />III. TANK HISTORY <br />Was Tank tested? <br />Yes <br />VROI <br />No <br />Failed precision test ? <br />Yes <br />Ref/Year <br />No <br />Average Annual Precipitation <br />If yes, give date(s) <br />14 <br />Was a repair made to the tank system? <br />Yes <br />No <br />NAME OF <br />EVALUATOR <br />If yes, what was repaired? <br />Was repair done under inspection? <br />Yes <br />-L <br />Irr <br />No <br />IType <br />Were soil samples analyzed? <br />Yes <br />No <br />8T%E <br />TPH-G <br />TPH-01 <br />Pb/ED8 <br />of failure/discharge <br />catastrophic <br />long-term leakage <br />overfill <br />unknown <br />Score <br />S <br />other: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />Soil Samples Received <br />Yes <br />VROI <br />No <br />Depth to Ground Water <br />9p <br />Ref/Year <br />Slo <br />Average Annual Precipitation <br />A= <br />14 <br />10-25 <br />On -Site Wells) <br />Yes <br />NAME OF <br />EVALUATOR <br />No <br />Number & Type <br />Irr <br />Dao <br />Pub <br />5 <br />Score <br />S <br />Score <br />S <br />Score <br />Distance to Wells) frac Tank <br />ft; ft; ft <br />C <br />0 <br />R <br />10 pts <br />if <br />condition <br />C <br />0 <br />R <br />9 pts <br />if <br />condition <br />C <br />0 <br />R <br />5 pts <br />if <br />condition <br />V. Site Feature - Leaching Potential Analysis <br />E <br />is met <br />E <br />is met <br />E <br />is met <br />Minimum Depth to groundwater from the Soil Sample (feet) Z <br />>100 <br />51-100 <br />25-50\1 <br />Fractures in subsurface (applies to foothills or mountain areas) <br />None <br />Unknown <br />Present <br />Average Annual Precipitation (inches) <br />XXXXXX <br /><10 <br />9 <br />10-25 <br />xxxxxxx <br />26-40\2 <br />Man -Made conduits which increase vertical migration <br />of leachate (i.e., septic systems, water Wells, ponds) <br />None <br />q <br />I <br />Unknown <br />Present <br />Unique site features: Recharge area, coarse soil, nearby wells.C <br />At least <br />More than <br />Xxxxxx <br />More <br />1 <br />one <br />one <br />COLUMN TOTALS»>TOTAL POINTS <br />+ <br />+ <br />Lj <br />= 1f/ <br />Sample Result: (B T X OR E) <br />RANGE OF TOTAL POINTS <br />49 pts or more <br />- 48 <br />40 pts or less <br />B <br />T <br />X <br />E <br />B <br />T <br />% <br />E <br />T _`-� <br />?1Z <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) <br />1 <br />50 <br />50 <br />50 <br />.3 <br />.3 <br />1. <br />1. <br />NA\3 <br />Sample Result: <br />GASOLINE <br />1000 <br />100 <br />10 <br />-� - ; ZS� TPH - <br />MAXIMUM ALLOWABLE TPN LEVELS (PPM) <br />DIESEL <br />10,000 <br />1000 <br />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 <=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 ppn (gasoline) or 100 piss (diesel). <br />V). STAF- 3ECOMMENDATION/CONCLUSION <br />1. Are BTX & E or TPH Concentrations > Allowable Levels =Yes <br />2. Recommend Site Closure Yes 7 -No <br />No If Yes, Refer to Site <br />VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/JENIOR <br />ion for Evaluation <br />_ l <br />CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE <br />YES <br />VROI <br />REFERRED TO SITE MITIGATION FOR EVALUATION <br />YES <br />NOlVi <br />DATE REFERRED <br />/ / <br />DATE CLOSURE LETTER NAILED <br />NAME OF <br />EVALUATOR <br />EH Z3 80 (UGTWKSHT)\5/90 �/ <br />