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SAN JOAOUIPUBLIC HEALTH SERVICES/ENVIRONMENTAL <br /> HE AL'n DIVISION <br /> ATE '/_� —cf- <br /> 1 UGST WORKSHEET FOR SITE CLOSURE EVALUATION T <br /> n/ WEEPS CODE �L�L/L <br /> AME OF FACILITY 7�- I/ <br /> CTANK ID 71V <br /> DDRESS ,21 <br /> TANK SIZE �>�o UEL TYPE <br /> II. GENERAL SITE HISTORY <br /> Is permit current? es o ermit # <br /> acility Status Code oc.Soit/GW Cont es o <br /> unber of Tanks at facility g <br /> e of Tanks(if available) ype of Tank teel Fbrgl ngl Dual <br /> III. TANK HISTORY <br /> ,s Tank tested? es o ailed precision test ? es o If yes, give date(s) <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> as repair done under inspection? es o ere soil samples analyzed? es o TXE PH-G PH-D b/EDB <br /> IType of failure/discharge atastrophic long-term Leakage verfiLL nknown Cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es o epth to Ground Water of/Year , <br /> veragefcipitation = 4 0 25 <br /> n-Site WeIL(s) es o umber & Type Irr om ub <br /> S core S S core <br /> ft; ft; ft C 0 pts C C pts <br /> istance to Wells) from Tank 0 if 0 0 if <br /> R ondition Rcondition R ondition <br /> J. Site Feature - Leaching Potential Analysis E is met E is met E s met <br /> >100 1-100 25-50\1 <br /> inimum Depth to groundwater from the Soil Sample <feet) <br /> Fractures in subsurface (applies to foothills or maintain areas) <br /> U None Unknown 3resent <br /> xxxxx <10 9 10-25 xxxxxx 26-40\2 <br /> verage Annual Precipitation (inches) <br /> an-Made conduits which increase vertical migration Unknown resent <br /> f leachate (i.e., septic systems, water wells, ponds) None <br /> inique site features: Recharge area, coarse soil, nearby wells. At least lore than <br /> xxxx None one done <br /> COLUMN TOTALS»>TOTAL POINTS + <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS +9 pts or more 41 - 48 pts 40 pts or less <br /> /� — o��p" G%.as �1 � B T X EMAXIMLM ALLOWABLE B-T-X-E LEVELS (PPM) SO 50 .3 .3 1. 1. NA\3 <br /> ample Result: ASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) 100 <br /> TPH IESEL 10,000 1000 <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 BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX &. E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> V11. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> )ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> LAME OF <br /> :VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />