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# r. <br /> SAN JOACUlI1 Ct..,�TTPU81.IC HEALTH SERVICES/EHVIRONME4TAL HEAL.. �iVISION ATE <br /> �, �. <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> EEPS CODE <br /> AME OF FACILITY G �U GIrE. <br /> ADRESS �� 19 <br /> ANK ID 4 - <br /> Ik 1ANK SIZE �'9}Q ) UEL r <br /> it. GENERAL SITE HISTORY <br /># is permit current7 es a ermit 0 - aciti.ty Status Code oe.Soit/Gu Cont es o <br /> tanber of Tanks at facility ge of Tanks(if available) Z ype of Sank Leel Fbrgt ngl Dual <br /> Ill. TANK HISTORY <br /> RREMOVAL <br /> ested? es o ailed precision test 7 es a Ef yes, give date{s)ir made to the tank system? esNa f yes, what was repaired? <br /> "done under inspecti.on7 es a ere soil samples analyzed? esilure/discharge catastrophic long-term leakager: <br /> TVHISTORY (ATTACH INSP; TION REPORT FOR 517E DETAILS/COLLECT DATAFOR LEACHINGPOTENTIAL ANALYSTS) <br /> es Received es o epth to Ground water V0 of/Year j verage Annual Precipitation = 4 0-25 <br /> ll(S) es o umber & Type Irr om ub <br /> S core 5 Scare S 3c0ce i <br /> istance to Wells) from Tank ft: ft; r ft C Q pts C pts C pts <br /> 0. if 0, if O if <br /> R andition R audition R ondition <br /> . Site Feature - Leaching Potential Analysis E is met E is met E s met <br /> fnimurm Depth to groundwater from the Soil Sanpte tfeet)7���5 >1G0 1-100 25-50\1 <br /> Fractures -in subsurface (applies to faothilts or mountain areas) /0 None Unknown resent <br /> I <br /> verage A mual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration G <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown 1 resent <br /> nique site features: Recharge area, coarse soil, nearby wells. xxxx None I C? At least ore than <br /> one one <br /> 1 COLUMN TOTALS>>>TOTAL POINTS + J (b <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9,pts or more 41 - 48 pts 40 pts or less <br /> B T X E B T X E <br /> i' MAXIMLA ALLOWABLE B-T-X-E LEVELS (PPM) 1'; 50 50 50 .3 .3 1. 1. NA\3 <br /> ample %Result/•, ASOLINE 1000 100 10 <br /> j pp- l7' 3 D AXIMUM ALLOWABLE TRH LEVELS (PPM) <br /> TPH iESEL 10,000 1000 100 <br /> OOTNOTES:, ***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 tabte. <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 /> V1. STAFF RE CC444ENDATION/CONCLUS[ON Q t�J 5--11-5' ' �y,�L�(?-'71y�cY.�, •' zeC�li'L��'G�5'I'�( <br /> 1. Are HTR $ E or TPH Concentrations > Altox ble Levels Tes o S��.J Cr{lYW�iI�IGGyitl�lt �[r� <br /> # 2. Recommend Site Closure 1Y <br /> is I Ao If Yes, Refer to Site Mitigation for Evatuat ion <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> _ONCUR WITH STAFF RECCI.IMENDATION FOR CLOSURE fES 0 EFERRED TO SITE MITICATICN FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> LAME OF <br /> ;VALUA7OR <br /> EH 23 80 (UGTWXSHT)\5/90 <br />