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SAN JOAOU OUNTY PUBLIC HEALTH SERVjCES/ENVIRONMENTAL .TH DIVISION DATE <br />i. UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br />a SWEEPS CODE <br />NAME OF FACILITY r <br />TANK ID # - <br />ADDRESS 5 Pb G <br />TANK SIZE FUEL TYPE <br />II. GENERAL SITE HISTORY 1. 1 ** <br />is permit current? Yes No Permit # - Facility Status Code Doc.SoiI/GW Cont Yes No <br />Number of Tanks at facility <br />Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual <br />III. YANK HISTORY <br />Was Tank tested? Yes Na Failed precision test ? Yes No If yes, give date(s) <br />Was a repair made to the tank system? Yes No If yes, what Was repaired? <br />Was repair done under inspection? Yes No Were soil samples analyzed? Yes No BTXE TPH-D Pb/ED <br />TPH-G B <br />Type of failure/discharge catastrophic long-term leakage overfill unknown other: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />Soil Samples Received Yes No Depth to GrQund Water Ref/Year ; <br />Average Annual Precipitation A= 14 10-25 <br />On -Site Well(s) Yes No Number & Type Irr Dom Pub S Score S Score S Score <br />Distance to Wells) from Tank ft; ft; ft C 10 pts C i pts C 5 pts <br />o if O f 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) <br />>100 G 51-100 25-50\1 <br />None Unknown Present <br />Fractures in subsurface (applies to foothills or mountain areas) M <br />Average Annual Precipitation (inches) <br />xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br />Man -Made conduits which increase vertical migration None Unknown Present <br />of leachate (i.e., septic systems, water wells, ponds) <br />AI least) More than <br />Unique site features: Recharge area, coarse soil, nearby wells. xxxxxx None one one <br />COLUMN TOTALS>>>TOTAL POINTS <br />Sample Result: (B 7 X OR E) RANGE OF TOTAL.POINTS 49 pts or more 41 - 48 pts 40 pts or less <br />MT� ILI JE;T X EB T X EMAXIMUM ALLOWABLE 8 T -X -E LEVELS (PPM)0 50 50 .3 .3 1. 1. NA\3 <br />GASOLINE 1000 100 10 <br />Sample Result: <br />MAXIMUM ALLOWABLE TPH LEVELS (PPM) 100 <br />TPN DIESEL 10,000 1000 <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 />\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 />\3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br />VI. STAFF RECOMMENDATION/CONCLUSION <br />1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No <br />2. Recommend Site Closure Yes No *If Yes, Refer to Site Mitigation for Evaluation <br />Vit. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br />CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br />DATE REFERRED / / DATE CLOSURE LETTER MAILED <br />NAME OF rAt: Al <br />EVALUATOR <br />r <br />EH 23 80 (UGTWKS \5/90 <br />