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I I <br /> .I <br /> SAN JOA. COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL.YALTH DIVISION q / <br /> (. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE 1 O L/ <br /> AME OF FACILITY WEEPS CODE <br /> DRE55Ll <br /> TANK 512E -?;,() UEL TYPE f. <br /> II. GENERAL SITE HISTORY <br /> ti <br /> Is permit cj .1urrent? es o ermit - acility Status Code oc.Soil/GW Cant es o <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tank teel Fbrgl ng[ Dual <br /> i <br /> Iii. TANK HISTORY <br /> ' F <br /> Jas Tank tested? as o ailed precisionitest 7 es o If yes, give date(s) / / ; / / <br /> as a repair made to the tank system? es Noj f yes, what was repaired? <br /> Jas repair„done under inspection? es o ere soil samptes:analyzed? es I o TXE PH-G PH-D I b/EDB <br /> ype of failure/discharge atastrophic tong.term Leakage verfitL noun 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 Am'at Precipitation k= 4 0-25 <br /> -Site WeIL(s) os o umber 8 Type i Irr am: ub <br /> S score 5 Score S Score <br /> istance to Wells) from Tank ft; ft; ft C 0 pts C pts C pts <br /> O if 0 if 0 if <br /> q R rondition R condition R =ondition <br /> 1. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet)' y100 1-100 - 25-50]1 <br /> ractures in subsurface (applies to foothills or,mountain areas) None Unknown resent <br /> verage Amuat Precipitation (inches) 6-40xxxx <30 9 10-25 xxxxxx 2L <br /> Ian-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water welts, ponds) None Unknown resent• <br /> nide site features: Recharge area, coarse soil, nearby wells. At feast 4ore than <br /> xxxx None one one. <br /> f <br /> f) <br /> li COLUMN TOTALS»>TOTAL POINTS � + + <br /> ampte Result: (B T X OR E) I�RANGE OE TOTAL POINTS F9 pts or more 41 48 pts fI 40 pts or less <br /> T X E 8 IT IX I E <br /> rw` + MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NAL <br /> Sample Result: 1 <br /> SOLI <br /> 1000 100 10 <br /> Iw IMUM ALLOWABLE TPH''1LEVELS {JPP <br /> H 10,000 1000 100 <br />` <br /> FOOTNOTES. 11 "'If documented soil and/or ground water contamination is present, do]—no t comptete the leaching potential. <br /> r analysis. (i.e., site'�is currently on UGT Contamination List fosoil or ground water.) <br /> 11 If depth is > 5 ft, and < 25,Ift., score 0 points. If depth <_5 ft., do not use table. <br /> 12 If precipitation is > 40 inches, score 0 points. <br /> 13 Levels for BTX&E are not appt`icable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel), <br /> Vt. STAFF RECOMMENDATION/CONCLUS10N ,. <br /> 1. Are BTX & E or TPH Concentrations > AllowabL:i Levels Yes o <br /> 2. Recomsend Site Closure es D6o I If ''Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> t <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 <br /> VALUArOR <br /> EH 23 80 (UIGTWKSHT)\5/90 ll! <br /> II IF <br />