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SAN JO4b7N COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL-."'EALTH DIVISION <br /> I• UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY ✓!�I (JC WEEPS CODE 2zS S� <br /> DRESS ANK ID # - <br /> TANK SIZE UEL TYPE <br /> Z <br /> II. GENERAL SITE HISTORY <br /> *w <br /> Is permit current? es o ermit # - acility Status Code oc.Soil/GW Cont es o <br /> Number of Tanks at facilityAge of Tanks(if available) IType of Tank keelT Fbrgl I 1Sngt Dual <br /> I1I. TANK HISTORY <br /> Jas Tank tested? es o ailed precision test ? es oIf yes, give date(s)71 <br /> Jas a repair made to the tank system? IYes No 11f yes, what was repaired? <br /> Jas repair done under inspectionT eso ere soil samples analyzed? es o TXE PH-G PH-D b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfill nknown ther: <br /> 1V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es '/Imo epth to Ground Water /ops of/Year verage Annual Precipitation = 4 0-25 <br /> Site Well(S) IYes I 1'/ o umber & Type I r Irr I om ub IV' <br /> S core S core S core <br /> istance to Well(s) from Tank 'JO• ft; ft; ft C 10 pts C 9 pts C pts <br /> 0 if 0 if 0 'f <br /> R ondition R condition R ondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E s met <br /> inimum Depth to groundwater from the Soil Sample (feet) 10 >100 1-100 25-5011 <br /> Fractures in subsurface (applies to foothills or mountain areas) lo None Unknown resent <br /> Average Annual Precipitation (inches) KXXXXX <10 9 10-25 KXXxxxx 26-40L <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) 1a None Unknown resent <br /> pique site features: Recharge area, coarse soil, nearby wells. At least 4ore than <br /> xxxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS 367 + Q + <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> .3 370 <br /> -080 B I T X E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 150 .3 .3 1. 1. NA-L3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> ZAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil 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 /> ,L If precipitation is > 40 inches, score 0 points. <br /> L Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION , <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes o x <br /> 2. Recommend Site Closure es -)I' o 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 CLOSURE fES1 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />