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SAN JOAOCOUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAISALTH DIVISION <br /> 1• UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE �. �✓ <br /> AME OF FACILITY e WEEPS CODE V�5 <br /> DRESS / W L,//Y- LQ / _ TANK ID # - <br /> TANK SIZE UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? es o emit # - facility Status Code I 1Doc.Soi l/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tank tee! Fbrgl ngl I Duat <br /> 111. TANK HISTORY <br /> as Tank tested? es I o ailed precision test 1 ITes o If yes, give date(s) <br /> Jas a repair made to the tank system? es No f yes, what was repaired7 <br /> as repair done under inspection? as o ere soil samples analyzed? as o TXE PH-G PH-D b/EDB <br /> Type of failure/discharge atastrophic long-term leakage verfitl nknown I lother: <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 L�o of/Year I iii&; verage Annual Precipitation 4= 11 <br /> 4 0-25 <br /> On-Site WeLL(S) es o umber 8 Type Irr am ub <br /> S Score S Score S Score <br /> istance to Well(s) from Tank ft; ft; ft C 10 pts C 9 pts C5 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 /> inimum Depth to groundwater from the Soil Sample (feet) �56.io >100 1-100 0 25-50, 11 <br /> Fractures in subsurface (applies to foothills or mountain areas) 1 (] None Unknown resent <br /> verage Annual Precipitation (inches) Kxxxxx 00 9 10-25 xxxxxx 26-402 <br /> an-Made conduits which increase vertical migration //�� <br /> f leachate (i.e., septic systems, water wells, ponds) None —1 Unknown resent <br /> nique site features: Recharge area, coarse soil, nearby wells. At Least lore than <br /> xxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS 10 + ph:n + 3 <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS P pts or more 41 - 48 pts 40 pts or less <br /> ND (✓ B T E B T E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 -3 1. 1. NA13 <br /> Sample Result: ,J ASOLINE 1000 100 10 <br /> ii ppm WO-0 AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> Qi,�aw. TPHjpy� IESEL 1 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 /> J1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth r_5 ft., do not use table. <br /> L 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 <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o <br /> I2. Recommend Site Closure IYes I l�o I �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 <br /> VALUATOR ATOR I <br /> EH 23 80 (UGTWKSHT)\5/90 <br />