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SAN JOAOUjaNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL'UMTH DIVISION <br />1• UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE s ]� r�r 1 90 <br />AME OF FACILITY S !�✓ S1EEPs CODE z 3 7 S <br />$ DRESS Z.3 Z %_5— WAR <br />Y L:7 ' /l w C�. i ANK 1 D # © . <br />TANK SIZE UEL TYPE .CIA 4 <br />I1. GENERAL SITE HISTORY <br />Is permit current? es o ermit # - aciIity Status Code ac.Soil/GW Cont es o <br />umber of Tanks at faci(it <br />y ge of Tanks(if available) �� ype of Tank keed Fbrgl rgl Dual <br />III. TANK HISTORY „ <br />Jas Tank tested?es <br />esx <br />o <br />o <br />ailed precision test ? <br />es <br />o <br />verage Arcual Precipitation{ <br />!f yes, give dates) <br />Jas a repair made to the tank system? es No <br />f yes, what was repaired? <br />es <br />Jas repair done under inspection?es <br />a ere soil samples analyzed?,, <br />es <br />a <br />ub <br />TXE <br />PH -G <br />PH -D b/EDB <br />ype of failure/dischargeletastrophic <br />long-term leakage <br />verfill <br />nownthey: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA,FOR _- LEACH ING,POTENT51AALYSIS) <br />oil Samples Received <br />esx <br />o <br />epth to Ground Water <br />/Q` <br />of/Year <br />verage Arcual Precipitation{ <br />= <br />4_'> <br />0-25 <br />-Site Wells) <br />es <br />o <br />umber & Type <br />Irr <br />am I <br />ub <br />score <br />10 pt's <br />if <br />ondition <br />is met <br />S <br />C <br />0 <br />R <br />E <br />Score <br />9 pts <br />if <br />condition <br />is <br />S <br />C <br />0 <br />R <br />E <br />core <br />pts <br />f <br />ondition <br />istance to Wells) from Tank I <br />5 <br />Lo ft; ft; ft C <br />'1 <br />0 <br />i; <br />R <br />.Site.feature =-Leaching Potential,Analysi E I <br />met <br />s met <br />inimum Depth to groundwater from the Soil Salaple (feet). } <br />>100 <br />1-100 <br />25-5011 <br />ractures in subsurface (applies to foothills or mountain areas) <br />None <br />Unknown <br />>resent <br />verage Annual Precipitation (inches) xxxx <br /><1D 1 <br />10-25 <br />KXXXxxx <br />26-40i <br />Ion -Made conduits which increase vertical migration <br />Df leachate (i.e., septic systems, water wells, ponds) ! <br />None; <br />Unknown <br />j� <br />resent <br />pique site features: Recharge area, coarse soil, nearbywells. i <br />At least <br />ore than <br />xxxx <br />None <br />one <br />one <br />COLUMN TOTALS>>>TOTAL POINTS I O3 <br />+ <br />I 1:6 <br />+' <br />.5 <br />3 3 <br />ample Result: (B T X OR E) <br />z�yF � 0. o4sp/+M <br />RANGE OF TOTAL POINTS 9 pts or more <br />, <br />41 - 48 pts <br />40 -pts or less <br />B X <br />B <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) 1 50 50 <br />IE <br />50 <br />.3 <br />JT <br />.3 <br />X <br />1. <br />E <br />11. <br />NA13 <br />ample Result: <br />SOLINE 1000 <br />100 <br />10 <br />FAXIMUM ALLOWABLE TPH LEVELS (PPM) <br />rESEL <br />10,000 <br />1000 <br />100 <br />Z _TPH - (a <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 />-L2 If precipitation is > 40 inches, score 0 points. ii <br />,L3 Levels for BTX&C 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 I <br />2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluat4ion <br />VI -- - - - <br />ncrcK crnwx�iun - 1u nt LURrI.1:11:1) UT A SUPERVISOR/SENIOR <br />CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES O EFERRED TO SITE;MITIGATION FOR EVALUATION ES 0 <br />EA <br />E REFERRED / / ATE CLOSURE LETTER MAILED 'iE OF <br />LUATOR <br />I uu %uu1Nr,an1,P>2/Tu <br />