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SAN JQAQ[JIN COUNTY PUBLIC HEALTH <br /> SERVICES/EHYIRONHENTAL HEALTH DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AHE OF FACILITY �� r` ? WEEPS CODE 3 <br /> DRESS 36 3 _.v <br /> ANK 512E / �jQ O UEL TYPE <br /> II. GENERAL SITE HISTORY <br /> Is permit current? es I I4o IV ermit # - acitity Sia tus Cad.I Cont eso <br /> umber of Tanks at facility go of Tanks(if available) hype of lank teel Fbrgl ngl Dual <br /> I11. TANK HISTORY i{ <br /> as Tank tested? es a ailed precision test ? es o Ifyes, give dates) <br /> i <br /> Jas a repair made to the tank system? es No 11f yes, what was repaired? <br /> -r :M <br /> Jas repair done under inspection? es o ere soil samples analyzed? es �o TXE PH-G PN-D b/EDB <br /> p <br /> Type of failure/discharge atastrophic long-term leakage verfill nownj then: <br /> IV. REMOVAL HISTORY (ATTACH INSP TION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> .y ib <br /> �F <br /> Soil Samples Received es IVINO epth to Ground Mater 16 of/Year ; verage Annual Precipitation <br /> -Site Wells) es o umber & Type irr om ub <br /> S ScoreS core S core <br /> I istance to Wel!(s) from Tank I I-I ft; ft; ft C 0 pts <br /> b C 9 pts C pts <br /> 0 i1f 0 if 0 f <br /> R ondition R condition R ondition <br /> i. Site Feature - Leaching Potential Analysis E is met '° E is met E -s met <br /> inimum Depth to groundwater from the Soi! Sample (feet) >100 1-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) -None C Unknown resent <br /> verage Annual Precipitation (inches) 0<10 9 10-25 xxxxxx 26-40L <br /> L <br /> an-?Sade conduits which .increase vertical migration { <br /> f leachate (i.e., septic systems, water wells, ponds) one Unknown 5 resent <br /> h nique site features: Recharge area, coarse soil, nearby welts. jj At least 4ore than <br /> xxxx Hone + one one <br /> ,5 <br /> COLUMN TOTALS>x>TOTAL POINTS + 3 + 5 f` <br /> ample Result: (B T X OR E) RANGE OF TOTALPOINTS 9 pts or more a 41 48 pts 40 pts or less <br /> ND atQ sem, B r x E b B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM)19 50 50 50 !� .3 .3 1. 1. NAM <br /> ample Result: ,d ASOLINE 1000 100 10 <br /> dN� rt e( S Gt�G'I�f�w 1MUM ALLOWABLE TPH LEVELS (PPM) <br /> _" I TPH IESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not-emplete the teaching 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 precipitation is > 40 inches, score 0 points. ?# <br /> ]3 Levels for BTX&E are not applicable at a TPH concentration sof 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentratione > Allowable Levets Yes o <br /> 2. Recommend Site Closure eso If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE VESJ 0 I IIEF5RRED TO SITE M[7(GAT10N FOR EVALUATION fES O <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF i <br /> VALUATOR <br /> r <br /> EH 23 80 (UGTWKSHT)\5/90 I <br />