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' SAN JC N COUNTY PUBLIC HEALTH SERVICES/ENVIRONMEN <ALTH DIVISION p <br /> 1 UGST WORKSHEET FOR SITE CLOSURE EVALUATr <br /> F7. <br /> Ge k, f! r T . )f WEEPS CODE �—3 [� <br /> E �� a- � of __ ,. ANK iD a -D UEL TYPE ,I /L 41� ` <br /> ' II GENERAL SITE HISTORY - <br /> �,/ •a <br /> Is permit current? es o ermit # 3 9 Q Q �3 / y acility Status Code oc.Soil/GW Cant es o <br /> umber of Tanks at facilityge of Tanks(if Available) 15Z liype of Tank Leel Fbrgl ngl Dual <br /> ' iIl. TANK HISTORY <br /> as Tank tested7 es o ailed precision test 7 es o 11 f yes, give date s) / <br /> as a repair made to the tank system?keg No f yes, what was repairedo <br /> [as repair done under inspection? es o ere soil sairptes analyzed? es o 7xE PH-Gpe of failure/discharge atastraphlc long-term leakage verfill mown then, <br /> lo <br /> 1V. REMOVAL HISTORY (ATTACH IN 11 CTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> ' ori Samples Received es o epth to Ground Water 6) of/Year verage Annual Precipitation 4 0-25 <br /> -Site Wells) es o umber 3 Type 1rr om ub <br /> ?stance to Wells) from Tank ft; ft, 5 core S care S core <br /> ' ft C 10 pts C 9 PCs C i pts <br /> 0 if 0 if 0 if <br /> V. R ondition R conditionR ondltion <br /> Site Feature - Leaching Potential Anatysis E is met E is met E is met <br /> inimurn Depth to groundwater from the Soil Siurple (feet) .%3 >1001-100 25-50L <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) xxxx <i0 9 10-25 xxxxxx 26-401 <br /> an-Made conduits which increase vertical migration <br /> f Leachate (i.e., septic systems, water welts, ponds) None Unknown resent <br /> ique site features. Recharge area,' coarse soil, nearby wells. /� At least ore than <br /> ' xxxx None 7 one one <br /> COLUMN TOTALS»>TOTAL POINTS t O(7 ; 9 �] <br /> Sample Result- (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 411 - 48 pts 40 pts or less <br /> 'v YS 3 P h <br /> a T x E e T x E <br /> MAXIMUM ALLOWABLE B-T-x-E LEVELS (PPM) 1 SO 50 50 .3 3 1. 1. IVAi <br /> ' ample Result; IGI A50LINE 7000 100 10 <br /> IMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPM IESEL 10,000 1000 100 <br /> FOOTNOTES ***If documented soil and/or ground water contamination is present, do not coirptete the leaching potential <br /> analysis. (i.e., site Is currently on UGT Contamination List for soil or ground water.) <br /> If depth Is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft , do not use table. <br /> a? If precipitation is > 40 Inches, score 0 points. <br /> ' 13 Levels for BTX$E are not applicabte at a TPH concentration of 10 pprm (gasoline) or 100 <br /> ppm (diesel) <br /> Vi STAFF RECOMMENDATION/CONCLUSIDw /17T ?'Le> �Yet�l tY 2. ��W 2� tJ CLa <br /> 7� <br /> ' 1. Are BTX 11 E or TPH Concentrations > At Levels Yeso1 y <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> VI1. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> -------------------------- <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED G7 / / ATE LOSURE LETTER MAILED / <br /> 1 r / <br /> AME OF <br /> "VALUATOR <br /> EH 23 80 (UGTWKSHT)%5/90 x <br />