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SAN JOAO COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENAALTH DIVISION p <br /> I• UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE ! <br /> AME OF FACILITY V_ 1-71 WEEPS CODE I / ' 3 <br /> DRESS '/'( CMG3 /> t ANK ID'# - /76 3 <br /> (ANK SIZE d O UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? es o ytermit if - acility Status Code �'�' oc.Soil GW Cont es V To <br /> unbar of Tanks at facility Be of Tanks(if available) I C4,4 Type-of Tank Leel Fbrgl I ngl I Dual <br /> 111. TANK HISTORY <br /> Jas Tank tested? es I lv�o ailed precisi�n test 7 es I V/ o If yes, give date(s) <br /> Jas a repair made to the tank system? es V No f yes, what was repaired? 6,111197 <br /> as repair done under inspection? as 40 era soil sanples analyzed] Fes o -TK PH-G I PH-D b/EDB <br /> ype of failure/discharge atastrophic lung-term leakage verfiLl nknown I kther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oiL Samples Received e t. epth to Ground Water of/Year verage Annual Precipitation = 4 0-25 <br /> 11 <br /> -Site Welts) es I V�l I umber 8 Type Irr om ub <br /> S Score S Score S 3core <br /> _ istance to Wel l(s) from Talc t; ft; ft C 10 pts C 9 pts C i pts <br /> 0 if 0 if 0 if <br /> R zondition R conditi on R O iti0n <br /> W. Site Feature - Leaching Potential Analysis E is net E is net E is met <br /> Mnifluit Depth to groundwater from the Soil Sample (feet) >100 1-100 25-5011 <br /> Fractures in subsurface (applies to foothills or mountain areas) O None Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 xxxxxx 26.401 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> pique site features: Recharge area, course soil, nearby wells. At least 4ore than <br /> xxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS I t a i 5 If <br /> angle Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> IDK 3T4 E - )V o IDKN 1JD B T X E 0 T X E <br /> X S 7 MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 SO 50 .3 .3 1. 1. NAl <br /> ample Result: pSOLIME 1000 100 10 <br /> �o K N = !U D IMUM ALLOWABLE TPH LEVELS (PPM) <br /> 44 K S N n TPH IESEL 10,000 1000 100 <br /> OOTNOTES: •--If documented soil and/or ground water contanina tion is present, do not Caiplete the leaching potential <br /> analysis. (i.e., site is currently on UGT Contani nation List for soil or ground water.) <br /> 1l If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do rot use table. <br /> 1 If precipitation is > 40 inches, score 0 points. <br /> L Levels for HTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPH Concentrations > Allow Oil Levels Yes o <br /> 2. Reconmend Site Closure es o 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 /> AME OF <br /> =VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />