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SAN JOA COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTA> ALTH DIVISION <br /> 1• UGST WORKSHEET FOR,SITE CLOSURE EVALUATION; AE <br />,! AME OF FACILITY WEEPS CODE 2 Z O}3 <br /> DRESS + ' <br /> Ht)b r W4q-1cr 10c) TANK ID # - <br /> ANK SIZE UEL TYPE blew <br /> II. GENERAL SITE HISTORY <br /> w* <br /> Is permit current? eso ermit # - acility Status Code oc.Soil/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) iL)h': 1 yPe of Tank teel Fbrgl ngl I Dual <br /> 111. TANK HISTORY t <br /> as Tank tested? es o ailed precision test ? es o If yes, give date(s) <br /> I. as a repair made to the tank system? es No f yes, what was repa .iced? <br />' as repair done under inspection? es F No ere soil samples anaiyxed? esjP H-G PH-D b/EDB <br /> [Te of failure/discharge atastrophic long-term Eeakage verfill nknown er: <br /> n <br /> IV. REMOVAL HISTORY (ATTACH INSPECT ON REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Ili oil Samples Received es 1 W4. epth to Ground Water ql) of/Year ,pry 1�$� verage Annual Precipitation = 4 D 2S <br /> -Site Wel (s) es o umber 8 Type Irr om ub E <br /> 5 ;d core S Score 5 care <br /> istance to We M s) from Tank ft; ft; ft C i1 10 pts C 9 pts C pts <br /> 0 if 0 if 0 f <br /> R i� ondition R condition R ondition <br /> V. Site Feature - Leaching Potential Analysis EIisis met E is met E s met <br /> inimum Depth to groundwater from the Soil Sample (feet)*- 3 _�� >300 1-100 25-5011 <br /> ractures in subsurface (applies to foothills or mountain areas) ba None Unknown resent <br /> verage Annual Precipitation (inches) KXXxxx c10 9 10-25 xxxxxxx 26.4012 <br /> Ian-Made conduits which increase vertical migration �} <br /> Df leachate (i.e., septic systems, water wells, ponds) f� None Unknown resent <br /> nique site features: Recharge area, coarse soil, nearby wells, .I� At least 4ore than <br /> xxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS b + <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or mo:rre 41 - 48 pts 40 pts or less <br /> qffm <br /> B Ti X ko B JT X E <br /> �- T• 3.��pm X- Zz en, MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 <br /> 3 .3 1. 1. NA\3 <br /> ample Result: 2ASOLINE 1000 100 10 <br /> c���VuD h1 TPH•d AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> 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 List for soil or ground water.) <br /> L if depth is > 5 ft. and < 25 ft., score 0 points. If depth r_5 ft., do not use table. <br /> L If precipitation is > 40 inches, score 0 points. <br /> L3 Levels for BTX&£ are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION f <br /> Not-. 51I0(vw - e <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Y 810 <br /> 1,�, e�i[1•�lorol�r�G�J7 Qa��Q� <br /> 2. Recommend Site Closure IYels <br /> o If Yes, Refer to Site Mitigation for Evaluation c;Ghl000loni-eVi-- r'f;Zbiffb <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR f,L( Cb►[Gr4lacnZera �2�Z87�(ab <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE tESNO EF£RRED TO NYFMITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF. <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 ?' <br />