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I� SAN JO,1.�N COUNTY PUBLIC HEALTH SERVICES/ENVIRONMEN 'ALTH DIVISION <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATI, ATE <br /> AME Of FACILITY[ Q G`O -4.,,Q� IJP uEEPS CODE <br /> DRESS 7 <br /> TANK 1 <br /> ANK SIZE J 0 lriJ�..a D # 29 •/��C/! D� <br /> UEL TYPE 5 fe ✓ l <br /> 11. GENERAL SITE HISTORY !! <br /> Is permit current? es o ermit d " <br /> V acuity status Code 0/ 14—oc.—so il/GW Cont es o <br /> umber of Tanks at facility <br /> 0013 ge of Tanks(if available) ype of Tank feel Fbrgl ngl Oual <br /> 111. TANK HISTORY <br /> as Tank tested? es o acted precision test ? es o If yes, give date(s) <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> as repair done under inspection? as 401 ere soil samples analyzed? es o TXE PH-G PH-D b/E00 <br /> ype of failure/discharge=-tatrophic long-term leakage verfitL known ther: <br /> IV. REMOVAL HISTORY (ATTACH INSP CTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es o epth to Ground Water of/Year $� ; verage Annual Precipitation 4 0-25 <br /> Site Well(s) es o umber & Type Irr om Pub <br /> S core S core S core <br /> istance to Wells) from Tank ft; ft; ft C 0 pts C pts C pts <br /> 0 if 0 if 0 if <br /> V. R condition R condition R ondition <br /> Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimrum Depth to groundwater from the Soil Sanple (feet) w <br /> 31 >100 1 100 25 50�1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown 3resent <br /> verage Annual Precipitation (inches) xxxx <10 9 10-25 xxxxxxx 2E-40)2 <br /> Ian-Made conduits which increase vertical migration <br /> f teachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> pique site features: Recharge area, coarse soil, nearby wells. At least lore than <br /> xxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS + + J� <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> NDB TX E B T X E <br /> MAXIMUMALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 150 .3 .3 1. 1. NA\3 <br /> ample Result: ASOLINE 1000 100 10 <br /> Q � IMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPHIESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented Boit and/or ground water contamination is present, do not complete the leaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil 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 /> ,22 if precipitation is > 40 inches, score 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 TPH Concentrations > Allowable Levels Yes o •' <br /> 2. Recocmrend Site Closure 1Yes Lo If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION • TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSUREPATE <br /> 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / CLOSURE LETTER MAILED <br /> AME OF <br /> -VALUATOR . <br /> EH 23 80 (UGTWKSHT)\5/90 <br />