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SAN JOA(UIT4'OUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL h.,1tH DIVISION <br /> i. UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE 2 <br /> AME OF FACILITY I ECORD ID <br /> DRESS I O �V �. A,t& IrANK ID # 91� / Q <br /> ANK SIZE D C) UEL TYPE u <br /> Il. GENERAL SITE HISTORY <br /> Is permit current? es o ermit # - aciLity Status Code oc.SoiL/GW Cant es o <br /> lmoer of Tanks at facility 2_ ge of Tank(if available) [Type of Tank Leel I Fbrgl I ngl I Dual <br /> LII. TANK HISTORY <br /> Was Tank tested? es o ailed precision test ? es o If yes, give date(s) <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> as repair done under inspection? es �0 ere soil samples analyzed? es o TXE PM-G PN-D b/EDB <br /> Type of failure/discharge atastrophic tong-tern leakage verf ill noun I iother- <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es �( o epth to Ground Water of/Yr ;19 verage Annual Precipitation = 4 0-25 <br /> p ea <br /> an-Site WeMs) as o umber & Type Irr an ub <br /> S Score S Score S core <br /> iscance to Wett(s) from Tank ft; ft; ft C 0 pts C pts C pts <br /> 0 if 0 if 0 f <br /> R ondition R condition R ordition <br /> Site Feature - Leaching Potential Analysis E is met E is met E s met <br /> inimum Depth to groundwater from the Soil Sample (feet) 116 r-l- >100 1-100 © 25-50L1 <br /> Fractures in subsurface (applies to foothills or mountain areas) More Unknown resent <br /> (verage Annual Precipitation (inches) KXXXXX <10 9 10-25 xmxxxx 26-40L2 <br /> an-Made conduits which increase vertical migration <br /> f Leachate (i.e., septic systems, water wells, ponds) More 9 Unknown resent <br /> i <br /> nique site features: Recharge area, coarse soil, or welts. At least ore than <br /> (Mincipat=>2000 ft; domestic=>500 ft; irr/agricultural=present] None R one one <br /> COLUMN TOTALS»>TOTAL POINTS + 3` + D c.� <br /> jmpte Result: (S T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pis 40 pts or Less <br /> G.N[fp �A'1 B T X E B 1 X E <br /> X_ MAXIMUM ALLOWABLE 8-7-X-E LEVELS (PPM) 1 50 50 50 -3 -3 1. 1. NA13 <br /> 1ampte Result: � \ ASOLINE 1000 100 10 <br /> rt 100 ppM ) AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> J]yam y_TPHW IESEL 10,0001000 100 <br /> OOTNOTES: --If documented soil and/or ground water contamination is present, do not complete the teaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> N1 If depth is > 5 ft. and < 25 ft., spore 0 points. If depth <=5 ft., do rot use table. <br /> \22 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> 41. STAFF RECOMMEMDATI OH/CCNCLUSION <br /> 1. Are BTX & E or TPN Concentrations > Allowable Levels Yes aI <br /> i2. Recommend Site Closure L <br /> es o X If Yes, Refer to Site Mitigation for Evaluation <br /> V11. REVIEW EVALUATION - TO BE COMPLETED BY A`SUPERVISOR/LEAD SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO S[TE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> :.VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/94 <br />