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SAN JOAOU%RUNTY PUBLIC HEALTH SERVICE /ENVIRONMENTAL:TH DIVISION <br /> Z. UGST WORKSHEET FOR SITE CL SURE EVALUATION ATE .?2 99 <br /> AME OF FACILITY Lard t E u� Cn EPS CODE <br /> PRESS l�2 ARK ID # <br /> :r <br /> TANK SIZE 20 UEL TYPE df e,f <br /> II. GENERAL SITE HISTORY <br /> ** <br /> Is permit current? es o ermit # - acility status Code 3 oc.Soil/GW Cont es F �e <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tank ISteeL I V�brgL ngl Dual <br /> 111. TANK HISTORY rM <br /> as Tank tested7 es o ailed precision test ? es ✓ If yes, give date(a) <br /> w <br /> Jas a repair made to the tank system? Ires No I f 11-f-yes, what w s repaired? II <br /> as repair done under inspection? Nol . ere soil samplesanalyzed? es7Xf PH-G PH-D b/EDB <br /> o <br /> ype of failure/discharge atastrophic long-term leakage erfitL nknown ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECI DATA FOR LEACHING POTENTIAL ANALYSIS) I� <br /> Solt Samples Received eso epth to Ground nater ef/ ear s verage Annual Precipitation = 4 0-25 <br /> •Site Wells) es 10, umber 8 Type 11 r I / cm u <br /> 5 score S Score S core <br /> istance to Well($) from Tank �So' ft; ft; ft C 10 pts C 9 pts C pts I <br /> 0 if 0 if 0 f <br /> R condition R condition R ondition <br /> Site Feature - Leaching Potential AnaLysis E is met E is met E is met (� <br /> inimum Depth to groundwater from the Soil Sample (feet) ,, b f >1D0 1-100 25-5011 <br /> Fractures in subsurface (applies to foothills or mountain areas) �d None Unknown resent, <br /> verage Annual Precipitation (inches) xxxx <10 9 10-25 xxxxxxx 26-40i <br /> i <br /> n-Made conduits which increase vertical migration <br /> Df leachate (i.e., septic systems, water wells, ponds) None Unknown resent. 1 <br /> pique site features: Recharge area, coarse soil, nearby wells. At least ore than <br /> xxxx None one one <br /> COLUMN TOTALS»),TOTAL POINTS 1/0 * <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 .6 B 7 X E B JT X E I� <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (P ) 1 50 50 50 .3 .3 1. 1. NAL II <br /> ample Result-. ASOL NE 1000 100 10 <br /> IMUM ALLOWABLE TPH LEVELS (PPM} <br /> S/d <br /> TPH-6 IESE1 10,000 1000 100 R <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 UG Contamination List for soil or ground water.) j <br /> 11 if depth is > 5 ft. and -c 25 ft., score 0 pointi. If depth —5 ft., do not use table. i� J <br /> N2 If precipitation is > 40 inches, score 0 points I <br /> L Levels for BTX&E are not applicable at a 7PH concentration of 10 ppm (gasoline) or 100 ppm (diesel). .' <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX S E or TPH Concentrations > Allowable Levels Yes I Vo I <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation far Evaluation m <br /> V11. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR I <br /> ONCUR W17H STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERR 0 TO SITE MITIGATION FOR EVALUATION ES 0 I� <br /> RTE REFERRED )ATE CLOSURE LETTER MAILED <br /> h <br /> LOFTOR <br /> t <br /> EN 23 80 (UGTWKSHT)\5/90 <br />