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SAN JOA*COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTJDcALTH DIVISION <br /> I• UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE , <br /> AME OF FACILITY �rQU L L� VCS ,� IS FI"T/+L�l t-C2V 5 rANXEEPS CODE ZC4 dap <br /> DRESS 2 1�0•J ,`-,� l)✓fl 1K.C'- �OCt�I ID k - Z• O <br /> {6 S-ol <br /> ANK SIZE 1,1 DO UEL TYPE ,e QS <br /> 11. GENERAL SITE HISTORY <br /> Rf <br /> is permit current? es o ermit F - acility Status Code oc•Soi L/GW Cant es o <br /> umber of Tanks at facility ge of Tanks(if available) I IT <br /> ype of Tank teel Fbrgl ISnat Dual <br /> 111. TANK HISTORY <br /> IZtmcv�c� 6 ZU �(a <br /> as Tank tested? as o ailed precision test ? as o If yes, give date(s) <br /> Jas a repair made to the tank system? as No f yes, what was repaired? <br /> as repair done under inspection? es 1 40 ere soil samples analyzed? es o IS TXE PH-G PH-D b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfiLL nknown I ther: <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 3�5 of/Year ; 15(G. verage Annual Precipitation = 4 0.25 <br /> )n-Site WeIL(s) es )0 o umber & Type l Irr I am JK ub <br /> S Score S Score S Score <br /> istance to WeLI(s) from Tank o24 ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R ondition R condition R ondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) 3Aj_9; aE >100 1-100 CJ' 25-501 <br /> Fractures in subsurface (applies to foothills or mountain areas) t0 None Unknown resent <br /> verage Annual Precipitation (inches) xxxx <10 9 10-25 xmxxxx 26.4012 <br /> an-Made conduits which increase vertical migration 1733' <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown 15 resent <br /> pique site features: Recharge area, coarse soil, nearby wells. At Leastore than <br /> xxxxx None one 5 one <br /> Qo COLUMN TOTALS>>>TOTAL POINTS to . ( + <br /> 15. 8' Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> Id � ' 8X n1pG ,022-5 <br /> PFS"l 1 T X E B T X E <br /> MAXIMUM ALLOWABLE 8-T•%-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NAL <br /> Sample Result: ASOLINE 1000 100 10 <br /> � I IMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL- 10,000 1000 100 <br /> DOTNOTES: fff 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 /> L If precipitation is > 40 inches, score 0 points. <br /> L Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION K\ '- N, C<itr olsc� Jftl G{JfnlJ r¢,i�c r:. <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes o <br /> 2-2. Recommend Site Closure �es ILo I �If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AMEOF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)%5/90 <br />