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SAN JOAOLIIH_COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> I, UGST WOkKSHEET FOR SITE CLOSURE EVALUATION AE b <br /> AME Of FACILITY WEEPS CODE <br /> I <br /> DRESS II, 3 ANK ID N - <br /> TANK SIZE UEL TYPE JA <br /> i!. GENERAL SITE HISTORY ~ <br /> ** <br /> Is permit current? es o ermit # - acility Status CodeaC.Soit/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tank teat Fbrgl ngl DuaL <br /> t <br /> Ill. TANK HISTORY <br /> Jas Tank tested? es o ailed precisionitest 7 es o If yes, give date(s) / <br /> Jas a repailr made to the tank system? iYes Noll <br /> f yes, what was repairedl <br /> as repair�'done under inspection? es o I ere soil samples analyzed? es o TXE PH-G PN-D 6/EDB <br /> ype of faiLure/discharge atastrophic long-term leakage verfitL noun ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> i <br /> oil Samptes Received es a epth to Gro" Water of/Year verage Annual Precipitation 4 0-25 <br /> Dri-Site Wetl(s} es o umber & Type : Irr ; am ub <br /> 5 Score S Score S 3core <br /> istance td Wet L(s) from Tank ft; ft; ft G 10 pts C pts C 5 pts <br /> 0 if 0 if 0 if <br /> R condition R condition R ondition <br /> V. Site Feature - Leaching Potential Analysis 4 E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) A >100 ,--51-100 .. - 25-50]1 <br /> ractures in subsurface (applies to faathilfs ar:mountain areas) r None Unknown resent <br /> verage AmuaL Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-402 <br /> ,I <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, Bonds) �� None r— Unknown resent- <br /> nique site. features: Recharge area, coarse soil, nearby wells. At Least 4ore than <br />' J Kxxxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS + + <br /> I I: $ i <br /> ample Result. (B T X OR E) ,RANGE Of TOTAL POINTS 9 pts or more 1 - 48 pts 40 pts or fess <br /> � B T X E B JT X E <br /> fi P MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NAL <br /> Sample Res : rGASOLINE 1000 100 10 <br /> IMUM ALLOWABLE TPH !LEVELS (PPM) <br /> ��� TPH IESFL 10,000 1000 iI 100 <br /> OOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the, leaching potential <br /> analysis. (i.e., sitelis currently on UGT Contamination List for soil or ground water.) <br /> -L1 If depth is > 5 ft, and < 25 ,1ft., score 0 points. If depth < 5 ft., do not use table. <br /> L If precipitation is > 40 inches, score :O points. <br /> 133 Levels for BTX&E are not appllicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br />?. VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TAH Concentrations > ALlowabte Levels Yes o <br /> 2. Recommend Site Closure es o If Yes, Refer to Site:Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 * EFERRED TO SITE MITIGATION FOR EVALUATION FS 0 <br />{ AYE REFERRED / / ATE CLOSURE LETTER MAILED <br />} AME OF 1 <br /> _VALUATO4 <br /> EH 23 80 (UGTWKSHT)\5/90 <br />