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SAN JOA*OUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAOLTH DIVISION <br /> I• UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE 75. <br /> AME OF FACILITY L-L)5 WEEPS CODE D <br /> DRESS '/O w �r—or^ / T cd, ANK ID p - <br /> TANK SIZE I I IFUEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? as o ermit k - acility Status Code oc.Soil/GW Cont es o <br /> umber of Tanks at facility lk <br /> ge of Tanks(if available) ype of Tank Leel Fbrgl ngl Dual <br /> III. TANK HISTORY <br /> Was Tank tested? esI1 I o ailed precision test ? as o If yes, give date(s) / <br /> Was a repair made to the tank system? as No 11f yes, what was repaired? <br /> Was repair done under inspection? es No ere soil samples analyzed? as o TXE I PH-G PH-D b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verf M nknown ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es o epth to Ground Water of/Year verage Annual Precipitation A, 4 11 <br /> 0-25 <br /> n-Site WeLL(s) es o umber 8 Type Irr om I ub <br /> S Score S Score S Score <br /> istance to WeLI(s) from Tank ft; ft; ft C 10 pts C 9 pts C5 Pts <br /> 0 if 0 if 0 if <br /> R onditi on R conditi on R onclition <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) 30- 16-16 >100 1-100 O 25-5011 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown rresent <br /> verage Annual Precipitation (inches) Kxxxxx <10 9 10-25 xxxxmx 26-40 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None 9 Unknown resent <br /> pique site features: Recharge area, coarse soil, nearby Wells. At least ore than <br /> xxxx None G one one <br /> COLUMN TOTALS»>TOTAL POINTS D a 2�' t <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 . 48 pts 40 pts or less <br /> B T X E B T I X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA_\3 <br /> Sample Resul1}OOOPt: 14 4PFP ASOLINE 1000 100 10 <br /> Pn77H AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> 4100C) 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 /> 11 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 /> 1 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION T l ® I !' ,• <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o l,l d nLknlb�ofuQ a$Op p.,bt, <br /> I iI 1,1c1lGhl D✓D¢'�a•Fl¢- 6„apo F0 <br /> I2. Recommend Site Closure tles I � 1f Yes, Refer to Site Mitigation for Evaluation TrnohlOro2{y-crty (00 <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR i. 1 020 NLD <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES INOI EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> NAME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 I —��( ��• 1`f a�.b �i� �IC�I�O✓IX,YLTL <br /> ND TI'jk ,1 ppb 1 �,17rlchkxU�ti�t-v.Q <br />