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SAN JOAOU&NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H DIVISION <br />(, UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE /3 -- <br />NAME OF FACILITY SWEEPS CODE J I <br />ADDRESS o � G 4 TANK [D X -ill 1 /► a <br />!TANK SIZE <br />1� �� IFUEL <br />TYPE Prerrni <br />6 / 46— <br />II. GENERAL <br />SITE HISTORY <br />If yes, what <br />was repaired?I <br />FIs permit <br />current?IYes <br />No <br />Permit <br />Facility <br />Status Coder � IDoc.Soil/GW Cont <br />Yesl X N <br />V <br />!Number of <br />Tanks at facility) <br />Age of Tanks(if available) <br />Type of TanklSteel <br />Fbrgl� Sngl Dual <br />III. TANK HISTORY <br />Score <br />9 pts <br />S <br />C <br />!Was Tank tested? IYes No failed precision test ? Yes <br />1'� INo! <br />X 1If yes, give dates) <br />6 / 46— <br />,Was a repair made to the tank system? <br />Yes No <br />If yes, what <br />was repaired?I <br />)Was repair done under inspection?IYes No <br />Were soil sampLes <br />analyzed? Yes <br />BNol BTXEI (TPH-G( jTPH-DI Pb/EJB( <br />;Type of failure/discharge) )catastrophic) `long-term leakagei <br />overfill unknown! <br />other: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />I <br />!Soil Samples ReceivedlYes Not (Depth to Ground Water <br />fRef/Year) (Average Annual Precipitation <br />A=114 110-25 <br />lan-Site WeLL(S) Yes Not (Number & Type <br />DATE REFERREDI C / / / <br />Irr <br />DATE <br />Dom` 1PubI <br />NAME OF <br />EVALUATORI�� <br />S <br />C <br />Score <br />10 pts <br />S <br />C <br />Score <br />9 pts <br />S <br />C <br />Score <br />5 pts <br />IOistance to WeLL(S) from Tankl ft; ft; ft <br />0 <br />if <br />0 <br />if <br />0 <br />if <br />R <br />condition <br />R <br />condition <br />R <br />condition <br />!V. Site Feature - Leaching Potential Analysis <br />E <br />is met <br />E <br />is met <br />E <br />is met <br />;Minimum Depth to groundwater from the Soil Sample (feet)! v — I'3 <br />1 <br />I >100 <br />I j51-100 <br />i <br />125-50\1 <br />!fractures in subsurface (applies to foothills or mountain areas) <br />V <br />1 None <br />1 I Unknown ! <br />!Present <br />i <br />!Average Annual Precipitation (inches) <br />�xxxxxx <br /><10 <br />I 9 110-25 <br />lxxxxxxxj <br />26-40\2 <br />Man -Made conduits which increase vertical migration <br />of leachate (i.e., septic systems, water wells, ponds) M10' <br />( None <br />! I <br />Unknown <br />`Present <br />!Unique site features: Recharge area, coarse soil, nearby wells. <br />xxxxxxl <br />None <br />I q <br />At Least <br />one! <br />More than <br />I one <br />ika S = TO A COLUMN TOTALS>>>TOTAL POINTS <br />!Sample Result: (B T X OR E) <br />�JK ;. N N 1) <br />RANGE OF TOTAL POINTS <br />1 <br />49 pts or more <br />I 41 - 48 pts I 40 pts or less <br />K!�' .� N 1) <br />a T <br />X E <br />B <br />IT <br />x <br />E <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) <br />1I 50I50� <br />50.3 <br />.3 <br />1. <br />1. NA\3 <br />SampleT�Lt: <br />K j D <br />�°.A TPH & <br />GASOLINE <br />MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br />DIESEL <br />1000 I <br />100 10 <br />10,000 I <br />1000 100 <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 IA&f Aa4CJ E-1'42Az;G',, 1 13/9- <br />1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No <br />2. Recommend Site Closure Yes No X <br />*If Yes, Refer to Site Mitigation for Evaluation <br />VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/S OR <br />CONCUR WITH STAFF RECOMMENDATION <br />FOR CLOSURE <br />IYESN01 <br />(REFERRED TO SITE MITIGATION FOR EVALUATION lYES NOI <br />DATE REFERREDI C / / / <br />DATE <br />CLOSURE LETTER MAILED <br />NAME OF <br />EVALUATORI�� <br />EH 23 80 (UGTWKSHT)\5/90 f <br />