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SAN JOAGUILIJUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H-w H DIVISION (O� — <br /> 1• UST WDRKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITYlopM ECORD ID ,3 -- <br /> ODRESS s.t [TANK ID # 3?- )0� <br /> ANK SIZE TYPE �C J o I Kpi Vic- <br /> 11. <br /> ,� <br /> 11. GENERAL SITE HISTORY f <br /> Is permit current? es o ermit # - !Facility Status Code oc.Soit/GW Cant es o <br /> umber of Tanks at facility ge of Tank(if available) type of Tank tee( Fbrgl ngl Dual <br /> 111. TANK HISTORY <br /> as Tank tested? es o ailed precision test ? es o if yes, give date(-) / <br /> Jas a repair made to the tank system? es No f yes, what was repaired? <br /> Jas repair done under inspection? as o ere soil samples analyzed? e5 o TXE I PH-G IT <br /> PH-D b/EDS <br /> Type of failure/discharge atastrophic long-term Leakage verfill noun ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es o epth to Ground Mater of/Year verage Amus( Precipitation N= 4 0-25 <br /> -Site Well(s) es o umber & Type Irr am <br /> S Score S Score 5 3core <br /> istance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R onditim R condition R ordition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inion Depth to groundwater from the Soil Sample (feet)`)-'//p":j`t >100 1-100 25-501 <br /> Fractures in subsurface (applies to foothills or mountain areas) 'v None Unknown Present <br /> verage Annual Precipitation (inches) xxxx <10 9 10-25 Kxxxxxx 26-40L <br /> an-Made conduits which increase vertical migration Nn <br /> f leachate (i.e., septic systems, water wells, ponds) None 1 Unknown Present <br /> nique site features: Recharge area, coarse soil, or wells. At least 4ore than <br /> [Mmcipa L=>2000 ft; domestic=>500 ft; irr/agricultural=present] xmx More one one <br /> t COLUMN TOTALS>>>TOTAL POINTS / U + l + I U <br /> ,f ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts _Aa-p -or less <br /> S g) ��+ 8= �/ B T X E B T X E <br /> i7X��" MAXIMLM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NAL <br /> am�py sJt:;o�.,r pptic, AXIMUM ALLOWABLE TPH LEVELS (PPM) ASOLINE 1000 100 10 <br /> O-.8° 1 I a'fPit�FPH IESEL 10,000 1000 100 <br /> 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 /> L If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION �, <br /> S R le ,w/1 D!4J <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes o �.�eYj ``� �/pa—�, LC <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for EvaluationGLrilfi <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR OX W * <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES O I EFERRED TO SITE MITIGATION FOR EVALUATION ES I 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/94 <br />