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SAN JOAOUII INTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL I -H DIVISION <br />I. `rJGST WORKSHEET FOR SITE CLOSURE EVALUATION ../ ATE <br />AHE OF FACILITY P ,Dt ibu4/ EEPS CODE /d <br />DDRESS O Cti FANK ID <br />TANK SIZE Soo IFUEL TYPE I R ,,fj_ <br />TI r.FwFasm OITF wleTnov <br />permit current7 eso ermit N - acility Status Code C oc.Soil/GW Cont es o <br />mer of Tanks at facility be of Tanks(if available) UN� ype of Tank teem ✓ Fbrgl I ngl I Dual <br />111. TANK HISTORY <br />Jas Tank tested? <br />es <br />I VII. <br />a <br />I IF <br />ailed precision testi <br />If es <br />I <br />Ifo <br />If <br />yes, give date(s) <br />4 <br />IT <br />Jas a repair made to the tank system? es No I' f yes, what was repairedT <br />till -Site Wel t(s) <br />os repair done under inspection? <br />es o <br />I V�ere soil sanples analyzed? ITes <br />umber 8 Type <br />o 1 <br />T%E <br />11 <br />I <br />PII-G <br />I <br />PH -D <br />I <br />b/EDB <br />Type of failure/discharge <br />atastroph is <br />long-term leakage <br />I <br />loverf i ll <br />nknown <br />I <br />ther: <br />la <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />�c <br />1 <br />oil Samples Received <br />Ifas <br />I <br />a <br />epth to Ground water <br />kilT <br />of/Year <br />; '?6 <br />verage Annual Precipitation <br />i= <br />4 <br />IT <br />0-25 <br />11 <br />till -Site Wel t(s) <br />Ifes <br />I <br />If. <br />umber 8 Type <br />Irr <br />I <br />licai <br />ub <br />' <br />S <br />3core <br />S <br />Score <br />S <br />3core <br />once to Welt(s) from Tank <br />ft; ft; It <br />C <br />O <br />R <br />10 pts <br />if <br />onditian <br />C <br />O <br />R <br />9 pts <br />if <br />condition <br />C <br />o <br />R <br />5 pts <br />if - <br />orditions <br />1. Site Feature - Leaching Potential Analysis <br />E <br />is met <br />E <br />is met <br />E <br />is met <br />inimun Depth to groundwater from the Soil Sample (feet) <br />>100 <br />1-100 <br />25-50\1 <br />Fractures in subsurface (applies to foothills or mountain areas) <br />None <br />17 <br />Unknown <br />resent <br />verage Annual Precipitation (inches) <br />KXXXXX <br /><10 <br />9 <br />10-25 <br />KXXXXXX <br />26-40\2 <br />an -Made conduits which increase vertical migration <br />of leachate (i.e., septic systems, water wells, ponds) <br />/0 <br />None <br />Unknown <br />resent <br />nim(ue site features: Recharge area, coarse soil, nearb lls <br />(t't 'rwe. <br />xxxx <br />None <br />C% <br />At leas[ <br />one <br />ore than <br />ohne <br />�f COLUMN TOTALS» >TOTAL POINTS <br />/v <br />+ <br />a % <br />+ <br />T� <br />3aopte Result: (8 T % O�tRE) <br />RANGE OF TOTAL POINTS <br />,9 pts <br />or more <br />41 - <br />48 pts <br />40 pts or less <br />. x2104 _ e 7/ <br />8 <br />T <br />% <br />E <br />p�(K }Ta✓ ',�� <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) <br />1 <br />50 <br />50 <br />50 <br />.3 <br />-3 <br />1. <br />1. <br />NA\3 <br />ample Result:neft>C,�fni <br />,J 1?'] <br />/• TPN <br />AXIMUM ALLOWABLE TPH LEVELS (PPM) <br />ASOLINE <br />1000 <br />100 <br />10 <br />IESEL <br />10,000 <br />1000 <br />100 <br />OOTHOIES: •--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 BTXAE are not applicable at a TPH concentration of 10 pion (gasoline) or 100 ppm (diesel). <br />V1. STAFF RECOMMENDATION/CONCLUSION J-0 <br />1. Are BTX.& E or TPH Concentrations > Allowable Levels Yes o `Pqt A5 ? q�M <br />Z. Recommend Site Closure as o If Yes, Refer to Site Mitigation for Evaluation / <br />VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br />_ONCUR WIT" STAFF RECOMMENDATION FOR CLOSURE <br />FS <br />I <br />0 <br />EFERRED TO SITE MITIGATION FOR EVALUATION <br />ES <br />I <br />0 <br />)ATE REFERRED <br />/ / <br />ATE CLOSURE LETTER MAILED <br />LAME OF <br />VALUATOR <br />❑I 21 80 (UGTWKSBT)\5/90 <br />