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SAN JOASCOUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAOLTH DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE 5, <br /> AME OF FACILITY Lo WEEPS CODE <br /> DRESS 110 vJ ITANK ID # - <br /> TANK SIZE vn k UEL TYPE uh kn <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? es o ermit # - acility Status Code oc.Soi l/GW Con as o <br /> weber of Tanks at facility ge of Tanks(if available) ype of Tank IS <br /> Leel Fbrgt I 13n9L Dual <br /> 111. TANK HISTORY <br /> Was Tank tested? as o ailed precision test ? as o If yes, give date(s) <br /> Jos a repair made to the tank system? as No f yes, chat was repaired? <br /> as repair done under inspection? es F <br /> o ere soil samples analyzed? es o TXE PH-G PH-D b/ED8 <br /> Type of failure/discharge atastrophic long-term leakage verfill nknownlather: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es 1 141- epth to Ground Water ,6 of/Year (9�rb verage Annual Precipitation R= 4 0-25 <br /> n-Site WeLL(s) es o umber 8 Type Irr om ub <br /> S core S core S core <br /> istance to WeLl(s) from Tank 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 is met <br /> inimun Depth to groundwater from the Soil Sample (feet)3D 10, ao >100 1-100 b 25-50L <br /> Fractures in subsurface (applies to foothills or mountain areas) ID None Unknown resent <br /> verage Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxx 26-401 <br /> Ian-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> pique site features: Recharge area, coarse soil, nearby wells. At least ore than <br /> xxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS (0 + <br /> Sample Result: 1/(B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> N V `���b� <br /> MAXIMUM ALLOWABLE B-T•X-E LEVELS (PPM) B 50 50 50 .3 .3 1. 1. NA�3 <br /> Sample Resullt:rj'appmr ASOLINE 1000 100 10 <br /> 000 F�ya 1 IMUM ALLOWABLE TPH LEVELS (PPM) <br /> 4600 TPH P IESEL 10,000 1000 100 <br /> FOOTNOTES: *w*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 /> L If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> 1 If precipitation is > 40 inches, score 0 points. <br /> L Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION T-G a CP /0 <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o 7T' 24 15-3D, I\Ilnl�7�t� <br /> I2. Recommend Site Closure Yes I �(o I �+If Yes, Refer to Site Mitigation for Evaluation I —Zp (D 351 <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> rP�-d <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 •�y,� �,� � � 1 � <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 �7�. ra 2O IJr�b <br /> 44 i/l,Tl`Ti-1 c hl(>Nedra.v <br />