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� <br /> SAN JOA(XJIN C610Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL NEA&AIVISION <br /> i• UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE /�c�� 91 <br /> AME Of FACILITY I a \ ` l O o �WEEPS CODE S 7 8 <br /> DDRESScc) der hTv cls C ANK 1D # <br /> ANK SIZE UEL TYPE ctl)t5� <br /> 11. GENERAL, SITE HISTORY <br /> r* <br /> s permit current? es o ermit # acidity Status Code oc.Soit/GW Cont 1YQ8 o <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tank feet brgl ngl Dual <br /> III. TANK HISTORY <br /> Jas Tank tested? es o ailed precision test ? es I o If yes, give date(s)7/ <br /> Jas a repair made to the tank system? Yes No f yes, what was repaired? <br /> hs repair done under inspection? es o era spit samples analyzed? as X o TXE X PH-G PH-0 WEDS <br /> ypo of faiture/discharge atastrophic long-term leakage verfill known they: <br /> tV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received as 0 epth to Ground Water & of/Year verage Annual Precipitation = 4 0.25 <br /> -Site Wett(s) es o umber & Type 11 rr I—lom ub <br /> S Score S Score S core <br /> istance to Wetl(s) from Tank ft; _f t; _„_,_,,,,_.•,-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 a stet <br /> i <br /> imimum Depth to groundwater from the Soft Sample (feet) >100 1-100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX 410 9 10.25 xxxxxxx 26-40\2 <br /> nn-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water welts, ponds) �� None Unknown resent <br /> lnique site features: Recharge area, coarse soil, nearby watts: At least 4ore then <br /> xx�x{x None one one <br /> COLUMN TOTALS»>TOTAL POINTS Z + l + <br /> artpto Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or less <br /> ddB T X E B IT X E <br /> T— .l7 13 MAXIMUM ALLOWABLE B-T X-E'LLVELS (PPM) 1 50 50 50 .3 .3 1 1. 1. NA\3 <br /> ample Result: ASoL1NE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPN IESEL. 10,000 1000 100 <br /> OOTNOTES: ***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 sol 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 TPN concentration of 10 ppm (gasoline) or 100 ppm (dieset). <br /> Vi. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Atlowabla levels Yes o <br /> 2. Recommend Site Closure1Y I es o if Yes, Refer to Site Mitigation for Evaluation <br /> Vil. REVIEW EVALUATION - TO BE CC14PLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES 0 EFERRED 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 />