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i SAN JOAOUILINTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H&M DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY WEEPS CODE 2 <br /> DRESS �' i) (�(' , YANK 10 # <br /> TANK SIZE UjjK UEL TYPE <br /> I1. GENERAL SITE HISTORY ** <br /> Is permit current? es o ermit # - acility Status Code oc.SoiL/GW Cont es o <br /> Number of Tanks at facility ge of Tanks(if availaFb <br /> ble) ype of Tank teel rgt ngI Dual <br /> III. TANK HISTORY <br /> Jas Tank tested? es o ailed precision test ? es 0 If yes, give date(s) <br /> as a repair made to the tank system? es No f yes, what was repaired? l <br /> Jas repair done under inspection? es o ere..soiL samptes analyzed? es a TXE PH•G PH-D b/ED8 <br /> ype of failure/discharge atastrophic long-term leakage verfitl nown I lother: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es a epth to Ground Water fp of/Year 9n verage Arcual Precipitation = 4 0 Z5 <br /> )n-Site Wells) es o umber & Type Irr 2 om ub <br /> S core S core' S core <br /> istance to Wells) from Tank �� ft; 5� ft; ft C 10 pts C 9 pts C i pts <br /> 0 if , 0 if 0 if <br /> R ondition R corkdition R ondition <br /> 1. Site Feature - Leaching Potential Analysis E is met E is mete- £ is met , <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 O 25-501 <br /> ractures in subsurface (applies to foothills or mountain areas) !O None Unknown resent <br /> verage Annuat Precipitation (inches) KXXXXX <10 9 10-25 . xxxxxxx 26-40_\2 <br /> ;1 <br /> Ian-Made conduits which increase vertical migration , <br /> f Leachate (i.e., septic systems, water welts, ponds) None Unknown J resent <br /> pique site features: Recharge area, coarse soil, nearby welts. At least 4ore than <br /> xxxxx None" one S one <br /> COLUMN TOTALS»>TOTAL POINTS I + 9 + 29 <br /> ample Result: (B T X OR E) RANGE OF TOTAL` POINTS 9 pts or more 41 - 48 pts 40 pts or less " <br /> 73 eel, b]( B T X E B JT x. E <br /> MAXIMUM ALLOWABLE B-T:-X-E" LEVELS (PPM) 1 . 50 50 50 .3 .3 1. 1. NAS <br /> ample Result: A ASOLINE 1000 100 10 <br /> �d4AX IMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH -G, IESEL 10,008 1000 100 <br /> OOTNOTE$: ***If documented soil and/or ground`water -contamination is present, do not complete the leaching potential <br /> analysis. (i.e., site is currently ori UGT Contamination List for soil or ground water.) <br /> \l If depth is > 5 ft. and < 25 ft., score 0 points. If depth -5 ft.., do not use table. <br /> X2 If precipitation is > 40 inches,iscore 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 TPN Concentrations > Allowable"Levels Yes1401 1 <br /> 2. Recommend Site Closure es No 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 ES 0 I EFERRED TO SITE MITIGATION FOR EVALUATION YES D <br /> ATE REFERRED /" / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> 'VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />