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SAN JOAWIYOUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> l• UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> AME OF FACILITY � WEEPS CODE <br /> " / <br /> DRESS I ANK ]0 # ( •�36 <br />! 3 rO <br /> i AHK SIZE 1� �Or� UEL TYPE <br /> II. GENERAL SITE HISTORY <br /> Is permit current? es o ermit # - acility Status Code Cont es o <br /> umber of Tanks at facility kge of Tanks(if available) ! ype of Tank Leel brg! ngE Dual <br /> Ill. TANK HISTORYf <br /> Jas Tank tested7 es o ailed precision test 7o es If yes, give date(s) <br /> Jas a repair made to the tank system? es No f yes, what was repaired? <br /> as repair done under inspection? as o ere soil samples analyzed? es o TXE PH-G PH-0 b/ED8 <br /> Type of failure/discharge atastrophic long-term leakage verfill nowni cher: i <br /> IV. REMOVAL HISTORY (ATTACH INSP TION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> r <br /> oil Samples Received eso epth to Ground Water ,6 d of/Year �6 Overage Annual Precipitation <br /> -Site WeLL(S) es o umber & Typo !rr am ub <br /> 5 core � S care S core <br /> istance to Wes) from Tank ft; ft; ft C 10 pts a C 9 pts C pts <br /> 0 Uf 0 if 0 f <br /> R ondition R condition R pondition <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) 1196_13�E 7 >100 ( 1-100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None j Unknown Present <br /> verage Annual Precipitation (inches) xxxx `}�10 9 10-25 xxxxxx 25-40L <br /> r an-Made conduits which increase vertical migration li <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown 3resent <br /> '7 <br /> nique site features: Recharge area, coarse soil, nearby wells. At least, ore than <br /> xxxx Hone q one one <br /> rr� [� <br /> COLUMN TOTALS>>>TOTAL POINTS t 3 (P t `J' -/ <br /> Sample Result: (8 T X OR E) RANGE OF TOTAL POINTS 9 pts or more j 41 - 48 pts 40 pts or less <br /> nn <br /> N b a- S a(1'� B T X E 8B JT X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 j .3 .3 1. 1. NAL <br /> app1e��Result: SOLINE 1000 100 10 <br /> T le if "• 11 IMUM ALLOWABLE TPH LEVELS (PPM) <br /> = 1 7 TPH IESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the teaching potential <br /> analysis. (i.e., site is currently on UGT Contamination Lisi for soil or ground water.) <br /> L If depth is > 5 ft. and < 25 ft., score 0 points. If depth i=5 ft. do not use table.. <br /> 12 If precipitation is > 40 inches, score 0 points. <br /> L Levels for BTX&E are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> �aoo r��. <br /> 1. Are 8TX & E or TPH Concentration > Allowable Levels Yes /1. <br /> 2. Reconwrd Site Closure es o 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 ES 0 I EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> L <br /> )ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> "VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> ,� i <br />