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SAN JOAOUIv COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL 1 4LTH DIVISION <br /> 1• UGST WORKSHEET FOR SITE CLOSURE EVALUATI ATE <br /> AME OF FACILITY WEEPS CODE <br /> DRESS <br /> ANK ID #t. - <br /> ANK 512E UEL TYPE <br /> 11. GENERAL SI HISTORY <br /> +t <br /> Is permit current? as o ermit # - acility Status Code oc.Soi l/GW Cont es o <br /> umber of Tanks at facility Be of Tanks(if available) ype of Tank Leel Fbrgl ngl I Dual <br /> 111. TANK HISTORY <br /> as Tank tested? es o ailed precision test 1 es o If yes, give date(s) <br /> Jas a repair made to the tank system? as No f yes, what was repained? <br /> Jas repair done under inspecti on7 es 40 ere soil samples analyzed? as o TXE PH-G PH-0 b/EDB <br /> ype of failure/discharge atastrophic long-teen leakageverfill nknown I lother: <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 2.6 of/Year ma; verage Annual Precipitation 4 11 <br /> 0-25 <br /> -Site Wells) es I o I umber & Type Irr I om I ub <br /> S 1 Score S i Score S 3core <br /> istance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R conditi on 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) 3S-1 D >100 1-100 J 25-5011 <br /> Fractures in subsurface (applies to foothills or mountain areas) �CJ None Unknown Present <br /> verage Annual Precipitation (inches) xxxx 00 9 10-25 xxxxxx 26.4012 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown Present <br /> nique site features: Recharge area, coarse soil, nearby wells. At least lore than <br /> xxxx None one c, one <br /> COLUMN TOTALS>>>TOTAL POINTS ID . �-� t S <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> BT X E 8 T X E <br /> MAXI NUM ALLOWABLE B-T•X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA13 <br /> ample Result: HIESEL <br /> 1000 100 10 <br /> J AXI MUM ALLOWABLE TPH LEVELS (PPM) <br /> 11 TPH— 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 UGT Contamination List for soil or ground water.) <br /> 11 If depth is > 5 ft. and < 25 ft., score 0 points. If depth <:5 ft., do not use table. <br /> L If prec ipitati On 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 , <br /> 1. Are BTX & E or TPH Concentrati ort > Allowable Levels Yes o <br /> 2. Recommend Site Closure lyes I�o I I<If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE CC14PLETED 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 />