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w <br /> SAN JOAQUINNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HNH DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE 3 <br /> AME OF FACILITY c.0� WW;Lg CODE <br /> DDRESS ( N f-tjj c? 1"4" TANK ID # <br /> TANK SIZE UEL TYPE Sy�SayZ LSL_, A <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? es o ermit # IFacility Status Code oc.Soil/GW Cont IYes o <br /> umber of Tanks at facility ge of Tanks(if available) IType of Tank ISteel Fbrgl I ISngl I Dual <br /> 111. TANK HISTORY <br /> as Tank tested? eso ailed precision test ? es o If yes, give dates) <br /> as a repair made to the tank system? Yes No 11f yes, what was repaired? <br /> as repair done under inspection? es o ere soil samples analyzed? es Jo TXE PH-GI IT PH-D b/EDB <br /> IType of failure/discharge atastrophic long-term leakage verfill nknown I lother: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es o epth to Ground Water cf/Year 9 verage Annual Precipitation = 4 10-25 <br /> Site WeLL(s) es o umber & Type Irr om ub <br /> S Score S Score S Score <br /> istance to Welt(s) from Tank ft; ft; —f t 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 /> inimKxn Depth to groundwater from the Soi( Sample (feet) >100 1-10025-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) ) None Unknownffxxxxxx <br /> resent <br /> average Annual Precipitation (inches) xxxxx <10 9 10-25 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> 1 leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> lnique site features: Recharge area, coarse soil, nearby wells. At Least lore than <br /> xxxxx None one one <br /> 2 <br /> COLUMN TOTALS»>TOTAL POINTS ('D - Z� - 0 J <br /> ample Result: (B TpX OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less$ I3tfI5 6 1 T X E B IT X E <br /> PPb MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result; GASOLINE 1000 100 10 <br /> AXIMUM 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 /> \1 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 /> \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. 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 'ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION YES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> -VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />