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SAN JOAOCOUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTALOLTH DIVISION <br /> I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE CJ, L-', <br /> AME OF FACILITY LU5+re — Cal Narne.{�Tl� 'WEEPS CODE 9005 <br /> DRESS 11D UJ Tv�✓l,e�.1 ANK ID # - <br /> TANK SIZE L)hK UEL TYPE LTr- l l <br /> II. GENERAL SITE HISTORY <br /> rr <br /> Is permit current es o ermit # - aciLity Status Code oc.Soi l/GW Con es o <br /> umber of Tanks at facility Be of Tanks(if available) Link- ype of Tank Leel Fbrgl ngl I Dual <br /> 111. TANK HISTORY GOrk-reAe- <br /> as Tank tested7 as o +11ed precision test 7 as o !f yes, give date(s) <br /> as a repair made to the tank system? as No yes, what was repaired? <br /> as repair time under inspection? as o ere soil samples analyzed? es 7%E H-G H-D /EDB <br /> Type of failure/discharge atastrophic long-term leakage verf ill nknown cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received EV <br /> o epth to Ground Water I.Y of/Year I lqg�j verage Annual Precipitation 4= 4 11 <br /> 0-25 <br /> )n-Site WaLL(s) es o umber 8 Type Irr om ub <br /> S Score S Score S Score <br /> istance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R onditi on R conditi on R ondi tion <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) 3DB'��= 7-8 >100 1-100 5 25-50L <br /> Fractures in subsurface (applies to foothills or mountain areas) J None Unknown resent <br /> verage Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxmx 26-40L <br /> Ian-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None `I Unknown resent <br /> nique site features: Recharge area, coarse soil, nearby wells. At leas[ 4ore than <br /> xxxxx None Cl one one <br /> COLUMN TOTALS>>>TOTAL POINTS ID + P-1 + 42- <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS P pts or more 41 - 48 pts 40 pts or less <br /> Ni'1 58 T % E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA1 <br /> Result: ASOLINE 1000 100 10 <br /> ;am <br /> &Oppm AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> _ TPH ip� IESEL 10,000 1000 100 <br /> 7 OOTNOTE S: rrrlf 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 /> L2 If precipitation is > 40 inches, score 0 points. <br /> 13 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION A_Z ') I , <br /> 1. Are BTX 8 E or TPH Concentrations > Allocable Levels Yes o L- <br /> I2. Recommend Site Closure�Yasl o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF 7 <br /> VALUATOR <br /> EN 23 80 (UGTWKSHT)\5/90 <br />