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SAN JOA01'J1NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL IN DIVISION <br /> I . UGST WORKSHEET FOR SITE CLOSURE EVALUATIO, _ DATE1 <br /> NAME OF FACILITY ,tom . ,.// /QQ� C SWECODE � J� ! / 7 <br /> C // <br /> � AODRE551 �� � r.- � /I V�Q C /"` • / TANKEPS I0 43 �- 4�P <br /> TANK SIZE 1d V � - FUEL TYPE <br /> I1 . GENERAL SITE HISTORY <br /> Is permit current? IYes No ( Permit = I - Facility Status Code j Doc . Soil /GW Cont Yes Nol <br /> 1Number of Tanks at facility ' ( Age of Tanks( if available ) Type of Tankl Steel Fbrgl Sngt Duali <br /> 111 . TANK HISTORY <br /> iWas Tank tested? Yes No Failed precision test ? Yes No If yes , give date( s ) <br /> Was a repair made to the tank system? Yes No If yes , what was repaired? <br /> i <br /> iWas repair done under inspection? IYes ) INo Were soil samples analyzed? Yes 11aI BTXEI TPH-GI ( TPH-D Pb/EDBI <br /> Type of faiLure/discharge catastrophic ( Long- term leakage ' ( overfill unknown ) other : <br /> IV . REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/CGLLECT DATA FOR LEACHING POTENTIAL ANALYSIS ) <br /> Soil Samples Received Yes NoI Depth to Ground Water bolRef/Year ) g6 Average Annual Precipitation A= 14 110-25 <br /> On- Site Wells ) Yes No 1Number & Type Irr 0oo � 1Publ <br /> S FScoreS Score S Score <br /> Distance to WeLL ( s ) from Tank ft ; ft ; ft C. C 9 pts C 5 ptsO 0 if O if <br /> R R condition R condition <br /> V . Site Feature - Leaching Potential Analysis _ (oc3/! E E is met E. is met <br /> ! Minimum Depth to groundwater from the Sail Sample ( feet ) 7 1 ) 100 1 15l - 100 125- 50\ 1 <br /> Fractures in subsurface ( applies to foothills or mountain areas ) I None 1 Unknown 1 Present <br /> ' Average Annual Precipitation ( inches ) XXX XXX <10 I 9 1 10- 25 Ixxxxxxx 26- 40\2 <br /> ' Man-Made conduits which increase vertical migration <br /> ! of leachate ( i . e . , septic systems , water wells , ponds) /C None Unknown Present <br /> jUni qe site features : Recharge area , coarse soil , nearby wells . At least ) More than <br /> X = > �arYt� xxxxxx Non <br /> e one one <br /> 1L j3 03 X <br /> E -3 — _ CO • N 07A S>»TOTAL POINTS 6/ D + l j} + <br /> 0 59 <br /> Sample Result : ( B T X OR 'c ) RANGE OF TOTAL POINTS 49 Pts or more 41 - 48 Pts 40 pts or less <br /> a ' ® MA MUM ALLOWABLE a- T-X- E LEVELS (PPM ) 9 50 50 50 . 3 I -3 1 . 1 . ,, NA\3 <br /> Samp esult :j GASOLINE 1000 100 10 <br /> Q D l F MAXIMUM ALLOWABLE TPR LEVELS (PPM ) <br /> r` TPH DIESEL 10 , 000 1000 1 100 <br /> FOOTNOTES : If documented soil and/or ground water contamination is present , do not ete the leaching potential <br /> pf� Z: IS, -7 (v T( H6;�— analysis. (i . e . , site is currently an UGT Contamination List for soil or ground water . ) <br /> 11 �y /� yP Jf depth is > 5 ft. and < 25 ft ., Score 0 points . If depth <=5 ft. , do not use table. <br /> 75 <br /> Tl # = ) J1 rpl4 ff precipitation is > 40 inches , score 0 points . <br /> 1/ \3 Levels for STX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel ) . <br /> VI . STAFF RECOMMENDATION/CONCLUSION 5 ' ° GLS 4" <br /> 1 . Are BTX & E or TPN Concentrations > Allowable Levels *Yes No I V t"W !/S; /`o �QQ�° <br /> 2 . Recommend Site Closure Yes No � • If Yes , Refer to Site Mitigation for Eva LuatYionN'^� <br /> . GY.LX/J 1 <br /> VII . REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVi SOR/SENIOR <br /> CONCUR 'WITH STAFF RECOMMENDATION FOR CLOSURE I YES ( NO ( REFERRED TO SITE MITIGATION FOR EVALUATION I YES NOI I <br /> DATE REFERREDi DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT ) \5/90 <br />