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SAN JOAGUI ANTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL *H DIVISION <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY ���. S - EEPS CODE l <br /> 0 S ' , ry nC ANK ID # <br /> DDRESS O (�)C& <br /> ANK SIZE UEL TYPE W Q <br /> 11. GENERAL SITE HISTORY ** <br /> la permit current? es o ermit # acility Status Code oc.Soil/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) Vice of Tank teal Fbrgl ngl Dual <br /> 111. TANK HISTORY <br /> Jas Tank tested? as o ailed precision test ? es o If yes, give date(s) <br /> as a repair made to the tank system? as No f yes, what was repaired7 <br /> ns repair done under inspection? esF No ere soil samples analyzed? as to TXE I PH-G PH•D b/EDB <br /> Type of failure/discharge atastrophic long-term leakage verfill nknown then. <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> .oil Samples Received as o I epth to Ground Water of/Year Cl�(p; verage Annual Precipitation = 4 10-25 <br /> )n-Site Well(S) IYes I o X umber 8 Type Irr I am I ub <br /> S Score S Score S Score <br /> istance to Well(s) from Tank ft; ft; ft C 0 pts C pts C pts <br /> ' '0 if 0 if 0 if <br /> R condition R condition R ondi Cion <br /> Site Feature . Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 •-- 1.100 Q 25.50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) InNone Unknown --."26-4 <br /> verage Annual Precipitation (inches) xxxxx <10 9 10-25 ,xxxxx <br /> an-Made conduits which increase vertical migration . ' T <br /> f leachate (i.e., septic systems, water wells, ponds) V None — Unknown resent <br /> Inique site features: Recharge area, coarse soil, nearby wells: At least lore than <br /> Exxxxx None <br /> /Jonaa <br /> COLUMN TOTAL S>»TOTAL POINTS l + <br /> nn llfl 1J ample Result: (0 T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 • 48 pts 40 pts or less <br /> Ft1CJ CIsP' llD r= B T % E 8 T % E <br /> 1 �� MAXIMUM ALLOWABLE B•T•X•E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: �(. ASOLINE, 1000 100 10 <br /> Q AXIMl1M ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL. 10,000 1000 100 <br /> OOTNOTES: ***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 ST%8E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION —�6 <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure es o I If Yes, Refer to Site Mitigation for Evaluation <br /> Vil. 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 /> AME OF <br /> .VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> Ex 29 80 <br />