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SAN JOAOUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTATH DIVISION <br />I UGST WORKSHEr7 FOR SITE CLOSURE EVALUATI 1DATE1 9 <br />NAME OF FACILITY I G JLC� (_ll� 5 f- ` I SWEEPS CODE) R3 7 <br />(ADDRESS( �� �f , (TANK [D X13 j�'�- r/'Ei . <br />TANK SIZE 5 (iv <br />� I FUEL TYPE 1.1 �%4 S v C' �i "`� <br />Ii. GENERAL SITE HISTORY <br />Is permit current? Iyes 1'XINoI IPermit ;*I - IFacility Status Code f�;�QDoc.Soil/G•a Cont IYes INo <br />I <br />(Hummer of Tanks at facility L�.� (Age of Tanks(if available)IIType of Tank lSteel l iFbrgl ISngtl Dual! <br />iii. TANK HISTORY ,( <br />TI I I ' ( yes, give date(s) <br />(Was lank tested' Yes INo1Failed precision test Yes No If � <br />Was a repair grade to the tank systeaftlYesl goI IIf yes, what was repaired?j <br />ivas repair done under inspection?YesINo1 Were soil samples analyzed? Yes Noi BTXEI 1TPH-GI ITPH-01 IPb/EDB, <br />!Type of failure/discharge) (catastrophic) (long-term leakage! ioverfiLLI (unknown (other: <br />IV. RE.MAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLI—EC DATA FOR LEACHING POTEaIAL ANALYSIS) <br />I l;Soil Samples Receivedl7es) INoI 1Deptts to Ground Water) IRef/Yeari , , (Average Annual Precipitation <br />A=114 110-25; <br />!On -Site Well(s)Yesl iNal INunoer & Typel 11rr) IDomI 1Pe>a1 <br />S <br />C <br />0 <br />R <br />E <br />Scare <br />10 pts <br />if <br />condition <br />is met <br />S <br />C <br />0 <br />R <br />E <br />Score <br />9 pts <br />if <br />condition <br />is met <br />S <br />C <br />0 <br />R <br />E <br />Scare <br />5 pts <br />if <br />condition <br />is met i <br />:Distance to Well(s) from Tank) ft; ft; ft <br />iv. Site -Feature - Leaching Potential Analysis <br />!Minimum Depth to groundwater from the Soil Sample Cfeet)6 0._ <br />I I )100 I I51-100 125-50\1 <br />!Fractures in suasur=ace (aopties to foothills or mountain areas)r <br />©I None I I Unknown I (Present <br />(Average Annual Precipitation (incnes) <br />(Man -Made conduits which increase vertical migration <br />hof leachate (i.e., septic systems, water wells, ponds) <br />�xxxxxxl <10 I 9 1 10-25 Ixxxxxxxl 26-40\2 <br />I None ' I Unknown , (Present <br />!Unique site features: Recharge area, coarse soil, nearby wells. <br />1=cc=1 <br />None <br />At least <br />one <br />More :hon <br />one <br />COLUMN TOTALS»)TOTAL POINTS <br />( <br />I <br />n <br />I I <br />Sample Result- (B T X OR E) <br />Tzr 'E30.5(A <br />• 0� i ( <br />RANGE OF TOTAL POINTS <br />49 pts or more i 40 pts or less <br />MAXIMUM ALLOWABLE B -T -X -E LEVEES CPPM)) <br />1� <br />7 X <br />50! 5a) <br />E B <br />50 .3 <br />T <br />13 <br />X <br />1.I <br />'c <br />1. <br />NA\3 <br />Sample Result: <br />GAJ . 0 Al I• • I__ rJ21 <br />TPH <br />MAXIMUM ALLOWABLE TPH LEVELS CPPM) <br />GASOLINE <br />1000 1 100 10 j <br />DIESE_' <br />10,000 I loco 1 100 <br />i <br />(FOOTNOTES: —if documented sail and/or ground water contamination is present, do`s _Cmorete the iearssins pocc,L,a. <br />i analysis. (i.e-, site is currently an UGT Contamination List for soil or ground water.) <br />\1 If depth is > 5 ft. and < 25 ft., scare 0 points. If depth (=5 ft., do not use table. <br />\2 If precipitation is > 40 inches, score 0 points. <br />\3 Levels for BTXLE 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 I"Yes) INoI I /��� ' <br />iZ. Recommend Site Closure IYes l INoI I If Yes, Refer to Site Mitigation for Evaluation plo / Z K <br />vI <br />I. REVIEW EVALUATION - TO BE COMPLETED SY A SUPERVISOR/SENIOR <br />CONCUR uITH STAFF RECOMMENDATION FOR CLOSUREIYESI NOI IRE—,ERRED TO SITE MITIGATION FOR EVALUATION!, YES OI <br />DATE REFERRED, / / (DATES CLOSURE LETTERMAIL D1 <br />_v •rr s� ,,,,--t,.-evTi � � ion <br />