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SAN J� JIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONNEk..:.L HEALTH DIVISION <br /> I• UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE J o -'5 7 J 7) <br /> AME OF FACILITY WEEPS CODE <br /> DRESS r��3 � / �l ANK ID if <br /> TANK 512E 11UEL TYPE 2 a ell <br /> 11. GENERAL SITE HIST Y / I <br /> -Cl <br /> Is permit current) Ifea o L- ermit Y - ecility Status Code �i`� oc.Soil/GWCont es o <br /> umber of Tanks at facilityT ge of Tanks(if available) Type'of Tank tee) Fbrgt nuI Dual <br /> Ill. TANK HISTORY <br /> as lank tested? as o ailed precision test 7 as o If you, give date(s) <br /> as a repair made to the tank systan? es 110 f yes, what was repaired? <br /> as repair done under inspactl on7 as o era soil samples unalyned7 es o 1T%E PN•G PH-D b/EDB <br /> Type of failure/discharge atustrophic lLng•term leakage verf ill mown cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> 'oil Samples ReceiveNefi o epth to Ground Water rf/Year verage Annual Precipitation 4 0.25 <br /> •Site Wells) es umber 8 Type Irr an ub <br /> S core S core S core <br /> is[ance to Wells) fran Tarilc ft; ft; R C 10 Pts C V pts C i pts <br /> 0 if O if 0 if <br /> V. k ondlrim R condition R oFditien <br /> Site Feature - Leaching Potential Analysis E is me[ E is filet E is WE <br /> inimun Depth to groundwater fran the Soil Saiple (feet)&(", >100 1.100 25-50]1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) xxxx <10 9 10-25 "XMA 26-40J2 <br /> on-Made conduits which increase vertical migration <br /> I leachate 0.e-, septic systama, water wells, ponds) None Unknown resent <br /> niclue site features: Recharge area, course soil, nearby wells. At least ore than <br /> xxxx None one one <br /> COLUMN TOTALS>»TOTAL POINTS .r <br /> apple Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or nmore 41 - 48 pts 40 pts or less <br /> T % E <br /> MAXIMUM ALLOWABLE B•T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NAL3 <br /> 'ample Result: ASOLINE 1000 100 lU <br /> MIN ALLOWABLE TPH LEVELS (PPM) <br /> / TPH IE SEL 10,000 1000 100 <br /> -OOINOTES: >==If documented soil and/or ground water contaninmtion is present, do not complete the leaching potential <br /> am lysis. (i.e., site is currently on OCT Contmdnation Lis[ for soil or ground water.) <br /> _1 If depth Is > 5 f[. urd < 25 ft., score 0 points, if depth 4=5 ft., du nut use table. <br /> J? It preclpitatlm is > 40 Inches, score 0 points. <br /> St Levels for BTXdE ore not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOIVIENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPN Concentrations > Al lowabte Levels Yes o <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH SCAFF RECOMMENDATION FON CLOSURE ES 0 EFENRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> )ATE REFERRED T ATE CLOSURE LETTER MAILED <br /> AME OF <br /> :VALUATOR <br /> Eli 23 bU (UGIWKSHT)\5/90 <br />