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SAN JOA0UIIi LG)NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL 4tTN DIVISION <br /> I• WEEPS CODE LOST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME Of FACILITY �3 <br /> DORESS !TANK ID p <br /> ANK SIZE ! G!1 UEl TYPE <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? es o ermit M acility Status Code oc.Soi l/GW Cont es Jo <br /> +umber of Tanks at facility) he of Tanks(if available) ype of Tank ISLeel Fbrgl I IS <br /> ngl I Dual <br /> 111. TANK HISTORY <br /> as Tank tested?Fe7s o ailed precision test ? as fiol If yes, give date(s) / <br /> as a repair made to the tank system? as No f yes, what was repaired? <br /> 05 repair done under inspection? es o ere soil samples analyzed? es to TKE PH-G PH-D b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfill mknown I la <br /> cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received as o epth to Ground Water of/Year verage Annual Precipitation A= 4 10-25 <br /> -Site Welts) es 0 umber 8 Type Irr an ub <br /> S Score S I Score S Score <br /> istance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C5 pts <br /> ' 0 if 0 if 0 if <br /> R onditi on R conditi on R ondition <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) >100 1.100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) O None Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 xxxxxxx 26.40\2 <br /> an-Made conduits which increase vertical migration <br /> 1 leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> Inique site features: Recharge area, coarse soil, nearby wells. At leastore than <br /> xxxxx None one J5 one <br /> COLUMN TOTALS>>>TOTAL POINTS /D i* y /U <br /> ample/Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> Pf"` O T % E B T I % E <br /> MAXIMUM ALLOWABLE B-T-%-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> -ample Result ///��� ASOLTNE 1000 100 10 <br /> N� ��/ ^ AXIMUM ALLOWABLE TPN LEVELS (PPM) <br /> /TPN IESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the leaching potential <br /> analysis. (i.e., site is currently on LOT 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 BT%8E are not applicable at a TPH concentration of 10 ppm (gasoline) or11100\.ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION 4 - f/� .� ../ <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o O/ '✓lam <br /> I2. Recommend Site Closure 1Y as I O If Yes, Refer to Site Mitigation for Evaluation <br /> V11. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> .ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE 'ES 'O 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)\5/90 <br /> EH 29 80 <br />