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SAN JOAW-;;�CUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL fit_ TH DIVISION <br /> I' UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> AME OF FACILITY n ATE <br /> � � ' �� � WEEPS CODE <br /> DDRESS [f�(/� l <br /> ANK SIZE r tOP ka . UEL TYPE <br /> 11. GENERAL SITE HISTORY <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) ]Type of Tank reel Fbrgl ngl Dual <br /> Tj <br /> 11{, TANK HISTORY <br /> psr <br /> nk tested? as o ailed precision test ? es o ✓ If yes, give date(s) <br /> repair made to the tank system? es No f yes, what was repaired? <br /> pair done underinspection? es o ere soil samples analyzed? es io TXE PH G PH D b/EDBf failure/discharge 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 Samples Received es o epth to Ground Water �� of/Year �� ; verage Annual Precipitation = 4 10-25 <br /> Site Well(s) es o I/ umber & Type Irr om ub <br /> istance to Wells) from Tank ft; ft; S core S core 5 core <br /> ft C 10 pts C 9 pts C pts <br /> 0 if 0 if 0 f <br /> R ondition R condition R ondition <br /> Site Feature - Leaching Potential Analysis E is met E is met E s met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) /r7 None Unknown Dresent <br /> average Annual Precipitation (inches) xxxxxx <10 9 10-25 Kxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) Iv None Unknown Dresent <br /> lnique site features: Recharge area, coarse soil, nearby wells. At least 4ore than <br /> xxxxx None 9 one one <br /> COLUMN TOTALS»>TOTAL POINTS ZN + I k + 3 <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 19 pts or more 41 - 48 pts 40 pts or less <br /> T.v3 t PP'"'' <br /> B T X E B T X E <br /> S(� <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> 'ample Result: ASOLiNE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPN IESEL 10,000 1000 100 <br /> AOTNOTES: ***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 /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure es ,�- o 1 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 YES KTOT7EFERRED TO SITE MITIGATION FOR EVALUATION YES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> _VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />