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SAN JOAW��W COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL-77,JALTH DIVISION <br /> I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE Z <br /> AME OF FACILITY WEEPS CODE 2Z 3 <br /> A.DDRESS — ANK ID # - <br /> TANK SIZE UEL TYPE <br /> 11. GENERAL SITE HISTORY 7 <br /> ** <br /> is permit current? Ifes o ermit # - acility Status Code oc.Soil/GW Cont IYes o <br /> _FI <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tank feel Fbrgl ngl Dual <br /> Ili. TANK HISTORY <br /> Jas Tank tested? 1Yes I IN01 ailed precision test ? 1Yes o If yes, give date(s) <br /> Jas a repair made to the tank system? es No 11f yes, what was repaired? <br /> Jas repair done under inspection? es No ere soil samples analyzed? es o TXE PH-G I IT <br /> PH-D b/EDB <br /> Type of failure/discharge atastrophic long-term leakage verfill nknown I lother: <br /> 1V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received 1Yes ✓ o epth to Ground Water /C6 of/Year Ob verage Amual Precipitation <br /> Site Wells) es ✓ o umber & Type 11r om ub <br /> S core S core S core <br /> istance to Wells) from Tank 7 U,ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <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) l0 >100 1-100 25-501 <br /> Fractures in subsurface (applies to foothills or mountain areas) b None Unknown Dresent <br /> verage Annual Precipitation (inches) xxxxxx <10 9 10-25 KXXXxxx 26-401 <br /> an-Made conduits which increase vertical migration <br /> Df leachate (i.e., septic systems, water wells, ponds) U None Unknown resent <br /> pique site features: Recharge area, coarse soil, nearby wells. At least 4ore than <br /> xxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS 30 + 4 + �$ <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS '9 pts or more 41 - 48 pts 40 pts or less <br /> B I T X E B JT X E <br /> x ` 3 t-p,- MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA)3 <br /> Sample Result: ASOLINE 1000 100 10 <br /> (� L AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPN fESEI 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the teaching 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 /> ,2 If precipitation is > 40 inches, score 0 points. <br /> 13 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 ✓ <br /> 2. Recommend Site Closure 1Yes 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 YES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES I 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />