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F h <br /> i � s <br /> j SAN JOAOU NTY PUBLIC HEALTH SERVICE5/ENVIRONMENTAL(IMO)ITH DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE !z . 31- <br /> AME OF FACILITY EEPS CODE r 7v <br /> DDRESS f $ L{.5 1: l J�4? / S 1 �O� I ANK 1D # 1 3 e7 r 3(,3_p2� <br /> TANK SIZE .It ODO uEL TYPE LIL�SGI <br /> .Ir <br /> It. GENERAL SITE HISTORY <br /> F .. <br /> Is permit current7 es o ermit # acility Status Code 5 L oc.Soil/GW Cont cs o <br /> ., <br /> umber of Tanks at facility 2 ge of Tanks(if available) 24ype of lank teel r 9 t ngt Dual <br /> o- <br /> 111. TANK HISTORY <br /> Ya+ie�4d tl3c S4 <br /> as Tank tested? es a I&Talled precision test ? es o If yes, give date(s) <br /> o- <br /> as a repair made to the tank system? Yes No f yes, what was repaired? <br /> ns repairldone under inspection? es oere'soil samples analyzed? es TXE -G PH-O b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfill nknown er: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR S1TE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL, ANALYSIS) <br /> Soil Samples Received es epth to Ground Wacer Ab of/Year ;.pverage Annual Precipitation = 4 10 25 <br /> site Well(s) es o umber & Type 1rr Om ub <br /> 5 Scare S Score 5 core <br /> ]stance to Welt(s) from Tank ft; ft; ft C 10 pts C 9 pts C i pts <br /> I 0 if 0 if 0 'f <br /> V. Site feature - Leaching Potential Analysis R ondition R ondition R onditionE 's met E is met E s met <br /> inimum Depth to groundwater from the Soil Sample (feet) 4D-d%29 >100 1-100 1 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown . resent <br /> I <br /> verage Annual Precipitation (inches) xxxxx <10 9 10-25 JKXXXXXX 26-40\2 <br /> o- <br /> an-Made conduits which increase vertical migration [� <br /> f leachate (i.e., septic systems, water wells, ponds) None —i Unknown resent <br /> tnique site features: Recharge area, coarse_ soil, nearby wells. At least ore than i <br /> r xxxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS + <br /> ample Result: (B T XO�E) m RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> il0?prn XB T x E B T X E i� MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 3 3 1. 1. NA\3 <br /> Sample Resu[t: laa5ottnQ ASOUNE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) j <br /> TP"ffm IESEL. 10,000 1000 100 <br /> OOTNOTES: F ***If documented soil and/or ground water contamination is present, do not complete the''teaching potential <br /> i� analysis. (i.e., site is currently on UGT Contamination List for Boit or ground water.) <br /> \1 1f 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 /> 4 \3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 <br /> ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CCWCLU510N <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes <br /> 2. Recommend Site Closure es o If Yes,-'"Refer to Site Mitigation for Evaluation <br /> a <br /> vil. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE fES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED / / `` <br /> AME OF P <br /> - _L__ <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 8a <br />