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SAN JOAOL 4OUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL .._ALTH DIVISION <br />I• UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE / <br />ANE OF FACILITY/ WEEPS CODE <br />DRESS�.� l f'� IV, 0,7 _ ANK IDM I,;� 4- / /_ � G� •—/ <br />TANK SIZE Q0C� 11EL TYPE <br />11. GENERAL SITE HISTORY <br />Is permit current? es o ermit M - / �. aclli ty St acus Code oc.Soll/GW Cont es o <br />umber of Tanks at facility _ ge of Tanks(if available) /Z > lype'of Tank [cel brgl ngl Dual <br />TANK HISTORY <br />Jas Tank tested? <br />es <br />V <br />o <br />j,' <br />ailed precision test 7 <br />as <br />of/Year <br />o <br />If <br />yes, give date(u) <br />4 <br />as a repair made to the t" syatan? <br />es No f yes, what was re(w iredl <br />eso <br />as repair done under inspection? <br />as <br />40 <br />ere soli samples analyzed? <br />es <br />Irr <br />o <br />un <br />f%E <br />I <br />PN -G <br />I PH -D <br />0 <br />E <br />b/EDD <br />S <br />C <br />0 <br />it <br />E <br />We of fuilure/discharge <br />istance to WeLL(s) fruit Tank <br />a[ostrophic <br />Lonp-term (eukage <br />Site Feature - Leaching Potential Analysis <br />verfill <br />sown <br />1 <br />10 they. <br />IV. REMOVAL HISTORY (ATTACH INSPEC')ION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL AWALVSISI <br />'oil Shaples Received <br />es <br />V <br />o <br />epth to Ground Water <br />of/Year <br />verage Annual Precipitation <br />. <br />4 <br />0-25 <br />-Site Well(s) <br />eso <br />O <br />ulber 5 Type <br />Irr <br />un <br />ANE OF <br />`VALUATOR <br />ub <br />S <br />C <br />0 <br />R <br />E <br />f <br />is uwt <br />0 <br />E <br />Score <br />9 pts <br />If <br />condition <br />16 liwt <br />S <br />C <br />0 <br />it <br />E <br />3core <br />i p[c <br />If <br />,andi t on <br />16 Wt <br />istance to WeLL(s) fruit Tank <br />ft; fG f[ <br />Site Feature - Leaching Potential Analysis <br />ininun Depth to groundwater from the Soil Swlple (feet) <br />>100 <br />-1.100 <br />25.50,. <br />fractures in subsurface (applies to foothills or mountain areas) <br />None <br />Unknown <br />resent <br />verage Annual Precipitation (inches) <br />xxxx <br />-10 <br />9 <br />10-25 <br />xMxxxx <br />26.40,.2 <br />an-Nade conduits which increase vertical migration <br />1 leachate (N.e., septic syataas, water Hells, ponds) <br />None <br />Unknown <br />resent <br />pique site features: Recharge area, coarse soil, nearby wells. <br />None <br />At least <br />one <br />ore than <br />one <br />COLUMN TOTALS>>>TOTAL POINTS <br />♦ <br />♦ <br />'wlple Result: (B T X OR E) <br />RANGE OF TOTAL POINTS <br />9 pts or more <br />41 40 pts <br />40 pts or less <br />MAXIMUM ALLOWABLE 0 -T•% -E GENETS (PPM) <br />1 <br />50 <br />SO <br />SO <br />.3 <br />3 <br />1. <br />1. <br />NAL <br />'ample Result: <br />TPH <br />ASOLINE <br />IMUM ALLOWABLE TPH LEVELS (PPM) <br />IESEL <br />1000 <br />100 <br />lU <br />10,000 <br />1000 <br />100 <br />FOOTNOTES: •••If documented soil and/or ground water contamination is present, do not coaplete the leaching potential <br />analysis. (i.e., site Is currently on OCT Cmtanirution List tar soiL or ground water.) <br />1J If depth Is > 5 ft. and c 25 ft., score 0 points. If depth �=S ft., do nat use table. <br />L2 If prec Mpitation is > 40 Inches, score 0 points. <br />L Levels for BTXKE ore not applicable at a TPM concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br />V1. STAFF RECOWMENDATION/CONCLUSION Cay G <br />N,°i7 <br />1. Are BTX 8 E or TPH Concent roti ons > A towable Levels Yes o /`� &-a<�S <br />2. RBCallliend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br />VII. REVIEW EVALUATION . TO BE COMPLETED BY A SUPERVISOR/SENIOR <br />ONCUH WITH STAFF RECOMMENDATION FOR CLOSURE <br />ES <br />0 <br />EFENRED 70 SITE MITIGATION fOR EVALUATION <br />ES <br />O <br />)ATE REFERREDCLOSURE <br />LETTER MAILED <br />ANE OF <br />`VALUATOR <br />u, cv uv Wuiwwni)%j/Yu <br />