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y <br /> SAN JOAOUINSVVdRTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEZZ4 DIVISION <br /> 1. US WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY ) RECORD ID I <br /> DRESS Cf'CW ANK ID # - I '?/ <br /> ANK SIZE UEL TYPE W szal /�, <br /> IL GENERAL SITE HIST Y VL^ <br /> 11 s permit current7 es o ermit # - acility Status Cade ac.Soil/GW Coni es o <br /> umber of Tanks at facility / ge of Tank(if available) ype of Tank IS <br /> teal Fbrgl ngl Dual <br /> Ill. TANK HISTORY �' 4Ah Met <br /> Jas Tank tested? es o ailed precision test ? es o If yes, give date(s) / / / / <br /> Jas a repair made to the tank system? es No f yes, what was repaired7 <br /> Jas repair done under inspection? es I Yo ere soil samples analyzed? es o TXE I iFPH-G 1 PH-0 b/EDfi <br /> ype of failure/discharge atastrophic long-term leakage verfill I Pnkno-n they: <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 Nater /0 of/Year 13& verage Annual Precipitation k= 4 0-25 <br /> -Site Wells) es o umber & Type Irr cm ub <br /> 5 core S core S Score <br /> istance to Well(s) from Tank ft; ft- ft C 0 pts C pts C pts <br /> 0 f 0 1f 0 if <br /> R ondition R adition R ondition <br /> J. Site Feature - Leaching Potential Analysis E -s met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet)Yb >100 I 1-100 I 5 25-50121 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) kxxxxx <10 9 10-25 26-40,L2 <br /> an-Made conduits which increase vertical migration R <br /> f leachate (i.e., septic systems, water wells, ponds) V <br /> I None Unknown Present <br /> nipue site features: Recharge area, coarse sail, or wells. n'�'I At least ore than <br /> (Muncipal=>2000 ft; domestic=>500 ft; irr/agricultural=present] None 1 one one <br /> COLUMN TOTALS»-TOTAL POINTS I Q s3'� <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> Ali ND, 'flOK Rif 8 THXB T X E <br /> �j 11 N.b `Sze,9 Kr / le- MAXIMUM ALLOWABLE B-T-K-E LEVELS (PPM) 1 50 .3 .3 1. 1. NASample Result: OLINE 1100 10 <br /> K Pi t IM)M ALLOWABLE TPH LEVELS (PPM) <br /> {e. TPH IESEL 101000 100 <br /> FOOTNOTES. "—Tf documented soil and/or ground water contamination is Present, to no ate the leaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> L 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 /> L Levels for 8TX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> Vt. STAFF RECOMMENDATION/CONCLUSION LOW 6/�) �, /r� ,U--(:O �[�!/ n <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes o13<1 <br /> sad'__40' Lt-N�^g+,QJV/('096-QK. <br /> 2. Recommend Site Closure e5 o 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 SITE MITIGATION FOR EVALUATION ES 0 <br /> )ATE REFERRED / / E CLOSUREZLETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/94 <br />