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SAN JOAOUI!*.„JNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H H DIVISION p <br /> I• UST WORKSHEET FOR SITE CLOSURE EVALUATION )ATE <br /> AME OF FACILITY N A!,rs ISL f i / ECORD ID <br /> ADDRESS O'��J�- L; ANK ID # <br /> TANK SIZE �`"� UEL TYPE `' <br /> IL G <br /> GENERAL SITE HISTORY `] T J[-�r� <br /> Is permit current? Ires o 1�4ermi # - acility Status Code '� oc.Soi L/GW Cont es o <br /> umber of Tanks at facility ge of Tank(if available) ype of Tank tee[ Fbrgl I Isrigt Dual FH <br /> III. TANK HISTORY <br /> as Tank tested? es o 1 IFailed precision test ? es o If yes, give date(s) <br /> as a repair made to the tank system? as No 1 11f yes, what was repaired? <br /> as repair done under inspection? es 1 40 ere soil samples analyzed es o TXE IT <br /> PH-G I Ir <br /> PH-D I b/EDB <br /> Type of failure/discharge atastrophic long-term leakage I loverfitt I lJnknc�wn I lother: <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 Water 10 of/Year >(, verage Annual Precipitation IL= 4 0-25 <br /> On-Site WeLI(s) es o umber & Type I Irr I am I ub <br /> S Score 5 Score S Score <br /> istance to welts) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R oncliticn R conditim R ordition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) D-- 13:,4 >100 1-100 25-50L <br /> Fractures in subsurface (applies to foothills or mountain areas) '9 Nane Unknown resent <br /> Average Annual Precipitation (inches) uxxxx <10 9 10-25 KMxmx 26-40L2 <br /> an-Made conduits which increase vertical migration <br /> f Leachate (i.e., septic systems, water welts, ponds) None Unknown resent <br /> pique site features: Recharge area, coarse soil, or wells. At Least 4ore than <br /> (Muncipal=>2000 ft; domestic=>500 ft; irr/agri cut turat=present) xxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS + + <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 19 pts or more 41 - 48 pts 40 pts or less <br /> B T X E 8 T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NAL <br /> Sample Result: ASOLINE 1000 100 10 <br /> AXIMUN ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 10,000 ? 1000 100 <br /> FOOTNOTES: ."*If documented soil and/or ground water contamination is present, do not compTere the leaching potential <br /> analysis. (i.e., site is currently on LET 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 BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> Vi. STAFF RECOMMENDATION/CONCLUSION `1 <br /> r(,t re.Gc, � �' DkO Y✓U !_/311ou�a b�f'_ <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes o c'_I Y) L-.- �,�/74pn"� <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation / ,z <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR w'pq/_ "'�'Lutj <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE 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 />