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SAN JOAOU Mt OUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL NEALTH DIVISION <br /> I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE — <br /> rAMIKOF FACILITY I EPS CODE <br /> C <br /> ESS TANK ID # <br /> SIZE UEL TYPE �a& + �)�� ' Q►W��I� <br /> It. GENERAL SITE HISTORY <br /> w <br /> s permit current? es o arm it # - acility Status CofdTank <br /> k oc.Sofl/GW Cont es <br /> r of Tanks at facility ge of Tanks(if available) ype feet brgl ( Dual <br /> 111. TANK HISTORY <br /> Jas Tanis tested? as o ailed precision test ? es o If yes, give e(s) <br /> Jas a repair made to the tank system? Yes No f yes, what was repaired? <br /> Jos repair done under inspection? es o ere soft samples analyzed? es o I TXE PH-G PH-D EDB <br /> type of failure/discharge tastrophic long-term leakage 7yerfitt I Jknon I they: <br /> 1V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soft Samptes Received es o th to Ground Water of/Year ; verage Annual Precipitation Lz 4 0-25 <br /> -Site Wett(s) es o r & Type Irr as <br /> S Score S Score S care <br /> istance to Welts) from Tank ft; ft; ft C IQ pts C 9 pts C pts <br /> 0 if 0 if 0 f <br /> R ondition R condition R wdition <br /> Site Feature - Leaching Potential Analysis E is met E is met E s met <br /> inia m Depth to groundwater from the Soil Sampte (feet) J Q >100 1-100 25-5011 <br /> ractures in subsurface (applies to foothitts or mountain areas) Nona Unknown resent <br /> v_rag* Annual Precipitation (inches) KXXXXX 00 9 10-25 Kxxxxxx 26-40L <br /> -Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) ` None Unknown resent, <br /> ique site features: Recharge area, coarse soil, nearby watts. At least 4ore than <br /> Kxxxxx None G� one one <br /> COLUMN TOTALS»>TOTAL POINTS + �7 + O 7 <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 4r'- 48 pts 40 pts or less <br /> 6- .,3Z x_,Is <br /> 'r_ .C1 I pp-h 8 T X E BT I X E <br /> ,4, D(¢- IMAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. i. MAa <br /> to Result: LIESEL <br /> NE 1000 100 10 <br /> INUM ALLOWABLE TPH LEVELS (PPM) <br /> • _� �Y�TPN � 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or grand water contamination is present, do not complete the leaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soft or ground water.) <br /> 11 If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> 1? If precipitation is > 40 inches, score 0 points. <br /> 13 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION ,. <br /> 1. Are BTX i E or TPH Concentrations > Allowable Levels Yes o Ix 1 <br /> 2. Recommend Site Closure as o 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 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> OF <br /> -VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />