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SAN JOAOUII6NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL #H DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE �.;2,0, (q <br /> �. <br /> AME OF FACILITY AvG Pumv avyj Weldivi WEEPS CODE ��-O8 <br /> DDRESS ANK ID_#] 1:-88i <br /> TANK SIZE 5 UEL TYPE QSau k <br /> 11. GENERAL SITE HISTORY LX <br /> Is permit current? as o ermit # I IFacility Status Code oc.Soil/GW Con es o <br /> umber of Tanks at facility C)' ge of Tanks(if available) I jflK [Type of Tankteal h/IFbrgl I �SngL_ .4ua1 <br /> l <br /> Ill. TANK HISTORY <br /> ns Tank tested? es I lHo ailed precision test ? as o if yes, give date($) <br /> as a repair made to the tank system? 1Yas No f yes, what was repaired? <br /> ns repair done under inspecti on7 es F Yo ere soil samples analyzed? Fas I V,+'01 TXE H-G PH-D b/EDD <br /> Type of failure/discharge atastrophic long-term leakage verfill nknown I VKIer: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS LLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> soil Samples Received es o ep[h to Ground Water tWref/Year 1qT& verage Annual Precipitation = 4 10-25 <br /> n-Site Welt(s) es o umber & Type Irr om I ub <br /> S 3core 5 Score S core <br /> istance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C pts <br /> 0 if 0 if 0 f <br /> R ondition R condi tion R ondition <br /> Site Feature - Leaching Potential Analysis 1 E is met E is met E 's met <br /> inimum Depth to groundwater from the Soil Sample (feet _Iyyt yj >100 1.100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) 10 None Unknown resent <br /> average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 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 /> )nique site features: Recharge area, coarse soil, nearby wells. At Least ore than <br /> xXXXXNone �J one one <br /> COLUMN TOTALS>>>TOTAL POINTS IV + r,^8 / + 7 <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or less <br /> T. t2D.l G T X E =.3 MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 NA\3 <br /> Sample Result: --SPI-+ ASOLINE 1000 100 � 10 <br /> 3UOD•0 TPH A%IMUM ALLOWABLE TPH LEVELS (PPM) IESEL 1 10,000 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 LOT 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 ppm (gasoline) or 100 Ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION �Q La4jA c Z y PP'" <br /> 1, Are BTX & E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure 1Y <br /> as o If Yes, Refer to Site Mitigation for Evaluation � � <br /> VII. REVIEW EVALUATION - TO BE COMPLETED IfY A SUPERVISOR/SENIOR <br /> .ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES JO <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF :222= -,+ <br /> ,,2^^ ,f al IG Y <br /> :VALUATOR Y r k0. - <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />