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SAN JOAOL,,_�OUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL\,,,/,LTH DIVISION <br /> 1• UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE -7)11 cI 6 <br /> AME OF FACILITY + r o s SWEEPS CODE <br /> DRESS ' � q , +C, W S.�CTANK ID # <br /> ANK SIZE 3r)o UEL TYPE Wo\ 2l/� S� ( c(C CrUr <br /> II. GENERAL SITE HISTORY <br /> ** <br /> Is permit current? es o IPermit # - acility Status Code oc.Soil/GW Cont 1Yes FT01 <br /> 64 <br /> umber of Tanks at facility $ f51�ChWg of Tanks(if available) ype of Tank tee( Fbrgl ngl Dual <br /> 111. TANK HISTORY -T1 <br /> Jas Tank tested? es o ailed precision test ? es o If yes, give dates) <br /> Jas a repair made to the tank system? Yes No 11f yes, what was repaired? <br /> as repair done under inspection? es No ere soil samples analyzed? 1Yes o TXE I PH-G I PH-D b/EDB <br /> ype of failure/discharge atastrophic Long-term leakage verfill nknown they: <br /> IV. REMOVALSTORY ATTACH INS ?191 <br /> E REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received les 1401 epth to Ground Water of/Year verage Annual Precipitation A= 4 0-25 <br /> n-Site WeLL(S) es o umber & TypeIrr om ub <br /> S Score S Score S Score <br /> istance to Well(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R ondition R condition R rondition <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) >100 1-100 25-5011 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown Dresent <br /> Average Annual Precipitation (inches) xxxxx <10 9 10-25 xxxxxxx 26-401 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown Present <br /> pique site features: Recharge area, coarse soil, nearby wells. OI At Least lore than <br /> xx}xxx None I one one <br /> COLUMN TOTALS>>>TOTAL POINTS ( + �� + 7 <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> X <br /> 1 ,y u 0 I P Pry, B T X E B JT X E <br /> 6 C� MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NAS <br /> ample ges lt: " ASOLINE 1000 100 10 <br /> IVAa�' S�ppm TP�� AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> J`�p Od /Yl TPH i� IESEL 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 /> 12 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 /> VI. STAFF RECOMMENDATION/CONCLUSION CJ- 3�,J <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes o 3am <br /> 5 b <br /> coo PP PP <br /> 2. Recommend Site Closure 1Yes 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 fES 0 EFERRED TO SITE MITIGATION FOR EVALUATION VES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />