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SAN JOADUIW,—4TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEWR'►:)IVISION <br /> UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> .ME OF FACILITY ! /moo I'� CORD ID <br /> r <br /> ESS � lANK 10 # " - /Sti7-SIZE /Ok x Tj UEL TYPE ✓�L q <br /> II. GENERAL SITE HISTORY <br /> s permit current? esINo ermit # - acility Status Code oc.SoiL/GW Cont es o <br /> umber of Tanks at facility ge of Tank(if available) I IT ype of Tank teel Fbrgl ng! Dual <br /> III. TANK HISTORY <br /> as Tank tested? es o ailed precision test ? es o If yes, give date(s) <br /> Was a repair made to the tank system? IYes No I ITf yes, what was repaired? <br /> Was repair done under inspection?fes F 40 ere soil samples analyzed7 es I Ito I I13TXE I ITPH-G I ITPH-O I IPb/EDB <br /> Type of failure/discharge atastrophie Long-term Leakage I Ioverfitl noun I lather: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received IYes o epth to Ground Water (;s' of/Year I Sr, verage Annual Precipitation Ik= 114 0-25 <br /> -Site Welt(s) Ilres o �( umber & Type Irr am ub <br /> S Scare S core 5 core <br /> (stance to Well(s) from Tank ft; ft; ft C 10 pts C pts C pts <br /> 0 if 0 1f 0 f <br /> R =ondition R andition R ondition <br /> W. Site Feature - Leaching Potential Analysis E is met E is met E s met <br /> inimum Depth to groundwater from the Soil Sample (feet) y� >100 I 1-100 1 5 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown Present <br /> verage Annual Precipitation (inches) Xx <10 9 10-25 Ix=u= 26-40)2 <br /> Ian-Made conduits which increase vertical migration <br /> f Leachate (i.e., septic systema, water wells, ponds) None Unknown resent <br /> nidue site features: Recharge area, coarse soil, or wells. At least are than <br /> [Muncipal=>2000 ft; domestic=>500 ft; irr/agricut tural=present] xxxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS • I S �{� <br /> amp le Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more I 1 - 48 pt 40 pts or less <br /> -�/!•0•L. 8 T I X E B T X E <br /> L•Q.L•oo�yg MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA13 <br /> Sample Result: SOLINE 1000 100 10 <br /> AXIMIR( ALLOWABLE TPH LEVELS (PPM) <br /> 1 ALG'W TPH Sr lESEL 10,000 1000 100 <br /> FOOTNOTES. --If documented soft 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 sail or ground water.) <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth c5 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 TPN concentration of 10 ppm (gasoline) or 100 ppm (dienet). <br /> Vi. STAFF RECOMMENDATION/CONCLUSION ,Q`j cCS• I�t. <br /> 1. Are BTX & E or TPH Concentrations > ALLowable Levels Yes o v <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> vil. REVIEW EVALUATION - TO BE CC14PLETED BY A SUPERVISOR/LEAD SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 I IREFERRED TO SITE MITIGATION FOR EVALUATi ON ES O <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF r <br /> VALUATOR <br /> EM 23 80 (UGTWKSHT)\5/94 <br />