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SAN JOAOUINNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HWH DIVISION { <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE _- :- .. <br /> AME OF FACILITY EEPS CODE <br /> �r <br /> DDRESS ANK ID # <br /> TANK SIZE fQ0C7 UEL TYPE <br /> Ii. GENERAL SITE HISTORY <br /> •r <br /> Is permit current? es o ermit # acility Status Code oc.Soil/GW Cont es o <br /> Umber of Tanks at facility ge of Tanks(if available) I 17y;:* of Tank teel Fbrgl ngL Dual <br /> Ill. TANK HISTORY �. >,` t°-- 3 -1-1 <br /> as Tank tested7 es o I lFailed precision test ? es' o if yes, give date(s) <br /> Was a repair made to the tank system? es No f yes, what was repaired? <br /> rrs repair done under inspection? es o ere soil samples analyzed? es to I TXE PH-G PH-D b/EDB <br /> ype of failure/discharge I atastrophic long term leakage verfill nknown ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> ,oil Somples Received es o epth to Ground Water of/Year verage Annual Precipitation = 4 10-25 <br /> Site WclI(s) es o I umber & Type irr om ub <br /> S 3core S Score 5 3core <br /> istance to Welt(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 ondition <br /> V. Site feature - Leaching Potential Analysis E is met E is met E is met <br /> inimtrm Depth to groundwater from the Soil Sample (feet) >100 1-100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain.areas) Q None Unknown 3resent <br /> verage Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown Present <br /> inique site features: Recharge area, coarse soil, nearby wells. q At least ore than <br /> xxxxx None ! one one <br /> COLUMN TOTALS»>TOTAL POINTS l� Z7 O <br /> ample Result: (B T X OR E) RANGE OF TOTAL POENTS 9 pts or more 41 - 48 pts 40 pts or less <br /> $�5 <br /> r(' ,6v1O P B TX E B X E <br /> m MAXIMUM ALLOWABLE B-T-X-E,LEVELS (PPM) 1 50 50 50 .3 J.T <br /> 3 1. .1. NA\3 <br /> SamptP Result: ASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS;(PPM) <br /> TPH 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 /> \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 /> VI. STAFF RECOMMENDATION/CONCLUSION u <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes o y 4 <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 /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE fES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF _ r. <br /> -VALUATOR <br />\ EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />