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SAN JOAoIiDUNTY PUBLIC HEALTH SERVICES/ENVIROHMENTALLTH DIVISION <br />I, UGST WORKSHEET FOR SITE CLOSURE EVALUATInN <br />AME OF FACILITY �,r) �d F WEEPS CODE <br />DRESS �jp(7 W q�-P� (00 �} ! ANK ID # <br />TANK SIZE UEL TYPE CLOoihu s <br />rt nENERAI SITE HISTORY <br />_.._._.- --'- ..._.--- <br />,M <br />permit current? es o ermit # - acility Status Code oc.Soil/GW Cont es o <br />:F <br />y <br />ger of Tanks at facility `J ge of Tanks(if availabEe) ;� ype of Tank Leel brgl 14ML Dual <br />111. TANK HISTORY <br />Jas Tank tested? <br />es 1 v4o <br />o <br />ailed precision test ? <br />es <br />o <br />of/Year <br />If yes, ;give date(s) 1D/ s p / <br />as a repair made to the tank system? es No <br />f yes, what was repaired? a riic5 vie -,v- �.Q55 ur% d <br />as repair done under inspection? <br />es o <br />ere soil samples analyzed, <br />es <br />'M <br />;F <br />o <br />TX <br />PH -G <br />PH -D <br />ub <br />b/EDB <br />ype of failure/discharge <br />atastraphic <br />long-term leakage <br />verfill <br />known <br />then: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />oil Samples Receivedes <br />o <br />epth to Ground Water <br />rj <br />of/Year <br />0 (�gt� <br />verage Annual Precipitation <br />N= <br />4 <br />0-25 <br />n -Site WeLL(S) <br />es <br />oumber <br />& Type <br />Irr <br />om <br />ub <br />r <br />Si <br />cone <br />S <br />Score 5 <br />3core <br />istance to WeLL(S) from Tank #t; ft; ft C <br />10 pts <br />C <br />9 pts C <br />i pts <br />0 ! <br />if , <br />ondition <br />is met <br />iF <br />0 <br />R <br />E <br />if 0 <br />condition R <br />is met E <br />if <br />ondition <br />is met <br />R } <br />c`� <br />V. Site Feature - Leaching Potential Analysis c)-�2 �`7 �iip,$� E <br />a <br />inimum Depth to groundwater from the Soil Sample (feet) a 5-17---� <br />33 1� <br />>100 <br />iF <br />1-100 5 <br />25-5D1 <br />ractures in subsurface (applies to foothills or mountain areas) ` 6 <br />None <br />Unknown <br />resent <br />verage Annual Precipitation (inches)xxxxx <br />a <br /><10., <br />9 <br />10-25 xxxxxx <br />26-40 2 <br />an -Made conduits which increase vertical migration DlVev'". <br />Df teachate (i.e., septic systems, water wells, ponds) Q r►�Q �j <br />None <br />q <br />Unknown <br />resent <br />pique site features: Recharge area, coarse soil, nearby wells. ; <br />At least <br />4ore than <br />xxxxx <br />None <br />E <br />one <br />one <br />I} <br />COLUMN TOTALS» >TOTAL POINTS � Q <br />t <br />� <br />t 5 <br />�7 <br />4'z <br />,i <br />ampte Result: (B T X OR E) <br />RANGE OF TOTAL POINTS 9 pts or more <br />41 - 48 pts 40 pts or less <br />T= <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) 15050 <br />T IXJE <br />50.3 <br />B <br />3 <br />J_T <br />X E <br />1. 1. NA13 <br />amps�gg Result: ASOLINE <br />TH GV - LD.T5 pp"AXIMUM ALLOWABLE <br />31000 p <br />100 10 <br />TPH LEVELS (PPM) <br />_ fi fdk, 4_& <br />10,000 <br />_TPH 1ESEL <br />.p <br />1000 100 <br />FOOTNOTES: ***If documented soil and/or ground water contamination is1present, do not complete the leaching potential <br />analysis. (i.e., site is currently on UGT Contaminationl`List for soil or ground water.) <br />11 If depth is > 5 ft. and < 25 ft., score 0 points. If depth < V ft., do not use table. <br />L If precipitation is > 40 inches, score 0 points. <br />,L Levels for BTX&E 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 TPN Concentrations > Allowable Levels Yes o. <br />2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for.:iEvaluation <br />VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br />CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE fES <br />0 <br />EFERRED TO SITE MITIGATION FOR EVALUATION <br />p <br />ES <br />p <br />ATE REFERRED <br />/ / ATE CLOSURE LETTER MAILED <br />I6 /1 / <br />AME OF <br />VALUATOR <br />z <br />EH 23 80 (UGTWKSHT)\5/90 " ' <br />E � <br />