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i <br /> SAN JOAOUI NTY PUBLIC HEALTH SERVICES/ENVTRONMENTAL jH DIVISION. C <br /> I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION OA7E 1 <br /> NAME OF FACILITY SWEEPS CODE !� S <br /> O 3 a G / TANK ID <br /> ADDRESS <br /> ;TANK SIZE r FUEL TYPE D7 ! V <br /> ;I: GENERAL SITE HISTORY <br /> Is permit current? Yes No Permit # - Facility Status Code DOc.SOiL/GW Cont Yes No <br /> ::Number of Tanks at facility Age of Tanks(if available) Type'of Tank Steel FbrgL SngL DuaL <br /> 'I1- TANK HISTORY <br /> :+as Tank tested? Yes No Failed precision test ? Yes No If yes, give date(s) / <br /> Was a repair made to the tank system? Yes l No ' If yes, what was repaired? { <br /> `+:as repair done under inspection? Yes No Were soil samples anaLyzed?(Yes No BTXE TAH-G TPN-D Pb/EDB <br /> !Type of failure/discharge catastrophic long'-term leakage overfilt�j unknown other: <br /> �I <br /> IV.' REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSTS) <br /> Soil Samples Received Yes No Depth to Ground Water Ref/Year Average Annual Precipitation A= 14 10-25 <br /> ;On-Site WeLL(s) Yes No , Number & Type Irr Dom Pub <br /> S Score S Score S Score i <br /> D4stance 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 condition R condition R condition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> :Minimum Depth to groundwater from the Soil Sample (feet) ��p. j [ . >100 51-100 25-50\1 <br /> i <br /> Frac,ures in subsurface (applies to foothills or mountain areas) ( 0 None Unknown Present <br /> 'Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) None Unknown (Present <br /> a <br /> :Unioue site features: Recharge area, coarse soil, nearby.wel,Ls. At Least More than <br /> xxxxxxi None one one <br /> 5 - 31 x W ) ry <br /> COLUMN TOTALS>>>TOTAL POINTS 1 D <br /> 'sampl Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts <br /> T 1 <br /> K p$ e&'S7 8 7 X E B T X E <br /> / MAXIMUM ALLOWABLE B-T-X E LEVELS (PPM) 1 SO 50 50 .3 .3 1. . 1 NA\3 <br /> I: <br /> Re�Lt:�D r*K (MAXIMUM ALLOWABLE TPH LEVELS (PPM) GASOLINE 1000 100 10 <br /> E k lS <br /> --r 3/V = e&TPHH DIESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the lea n <br /> anaLysis. (i.e., site is currently on UGT Contamination List for sail 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 /> \2 If precipitation is > 40 inches, score 0 points. <br /> i \3 Levels for BTX&E are nor applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel)- <br /> '11. STAFF RECOMMENDATION/CONCLUSION <br /> ! 1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No r <br /> 2. Recommend Site Closure Yes No *If Yes, Refer to Site Mitigation for EvaLuation <br /> V11. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR j <br /> ;CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES( NO� (REFERRED TO SITE MITIGATION FOR EVALUATION YES IN077 <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED{ <br /> i <br /> NAME OF <br /> EVALUATOR <br /> `cH 23 80 (UGTWKSHT)\5/90 <br />