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SAN JOACUi`�.4TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H� DIVISION <br /> I. UST(WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY \ 1YlOn L <br /> ` uw\bCnN- ECORD ID <br /> DRESS "I�'�, 1n1 1 ANK ID X <br /> VV 9 sz��zy3 <br /> ANK SIZE w^JS 1 UEL TYPE <br /> 11. GENERAL SITE HISTO <br /> is permit current? es oIx ermit k - aciliry Status Code ,j oc.Sail/GW Cont es o <br /> timer of Tanks at facilityLuk. ge of Tank(if available) Uv\.lL ype of Tank Leel KlFbrgt ngl Dual <br /> 111. iANK HISTORY <br /> as Tank tested? es o Un, 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 repaired7 <br /> Pas repair done under inspection? es I o I ere soil samples analyzed es o TXE I PH-G PH-D b/EDB <br /> ype of failure/discharge atastrophic Long-teen leakage verfill nownther: <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 Hater of/Year verage Annual Precipitation = 4 0-25 <br /> -Site uel L(s) esIx o unber S Type Irr an ub <br /> S core s core S core <br /> is:ante to Wel t(s) from Tank ,y- _ft; ft; ft C 0 pts C pts C pts <br /> 0 f 0 if 0 'f <br /> R ondition R ondition R and it ion <br /> Site Feature - Leaching Potential Analysis E 's met E is met E s met <br /> i nimu;, Depth to groundwater Iran the Soil Sanple (feet) >100 I 1-100 25-50\1 <br /> frac:ures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) xxxx <10 9 10-25 xzzx 26-40L <br /> an-Made conduits whirls increase vertical migration <br /> f Leachate (i.e., septic systems, water wells, ponds) None Unknow: \5' resent <br /> nicue site features: Recharge area, coarse soil, or wells. At leas[ ore than <br /> [Muicipal=>2000 ft; domestic=>500 ft; irr/agricultural=present] x None 9 one one <br /> COLUMN TOTALS>»TOTAL POINTS . � " . 4 <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more I 41 - 48 pts 40 pts or less <br /> g 8 T X E B 7 X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 3 1. 1. NAL <br /> g-I 4 pool fj�0 LINE 1000 100 10 <br /> 1 TOAC) IMUM ALLOWABLE TPH LEVELS (PPM) <br /> Yz SSI('JIESEL 10,000 1000 100 <br /> OOTNOTES- —If documented soil and/or ground water contamination is present, do not complete the leaching potential <br /> L.eQ6 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 <= ft., do not use table. <br /> S-I S N L If Precipitation is > 40 inches, score 0 points. <br /> L Levels for BTX8E are not applicable at a TPN concentration of 10 Rxn (gasoline) or 100 pqn (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1, Are BTX & E or TPH Concentrations > Allowable Levels Yes X o <br /> I2. Recommend Site Closure Ir esI No I p'If Yes, Refer to Site Mitigation far Evaluation <br /> JI 1. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES O EFERRED TO SITE MITIGATION FOR EVALUATION ESjr>0�0 <br /> ATE REFERRED _V / ✓L2 / S ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/94 <br />