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SAN JOADUINOTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL Ht01H DIVISION <br /> 1• UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> AME OF FACILITY �(p EEPS CODE <br /> DDRESS `3 0 V„r . ANK ID d <br /> TANK SIZE UELLTTYPE C� vv g' <br /> II. GENERAL SITE HISTORY <br /> Is permit current) es o ermit p acitity Status Code oc.SOWGW Cont es o <br /> umber of Tanks at faeil ity ge of Tanks(if available) ype of Tank Leel Fbrgl ngl I Dual <br /> 111. TANK HISTORY <br /> as Tank tested? es o ailed precision test es I ifo If yes, give date(s) <br /> as a repair made to the tank system? es #twg-tem <br /> yes, what was repaired) <br /> as repair done under inspection? es oil samples analyzed) as <br /> to TXE PH-G PH-0 b/EDB <br /> Type of failure/discharge atastrophicleakage verfill nknown 1 10cher: <br /> IV, REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Boil Samples Received es o epth to Ground Water 3d of/Year (>L 3 ��� verage Annual Precipitation kz 4 10-25 <br /> -Site WCLI(s) es o umber & Type Irr om ub <br /> 5 Score 5 Score S core <br /> Distance to WeIL(s) from Tank ft; ft; ft C 10 pts C 9 pts C pts <br /> O if 0 if O f <br /> R onditi on R condition R ondition <br /> V. Site Feature . Leaching Potential Analysis E is met E is met E 's met <br /> inimum Depth to groundwater from the Soil Sample (feet)/6 -50; � >100 1.100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown Present <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 xxxxxxx 26.40\2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> )nique site features: Recharge area, coarse soil, nearby wells. At leas[ ore than <br /> xxxx None �^ one Colne <br /> COLUMN TOTALS»>TOTAL POINTS { / / . O / <br /> ample .Result: (0 T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or less <br /> G 1 X E 8 i % E �. <br /> MAXIMUM ALLOWABLE O-T-X-E LEVELS (PPM) 1 � 50 50 50 .3 .3 1. 1. NA\3 <br /> -ample Result: m 1 AXIMUM ALLOWABLE TPH LEVELS (PPM) ASOL(NE1000 100 10 <br /> TPH 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 8TX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> Vt. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes <br /> 2. Recommend Site closure �as I ✓'�10I If Yes, Refer to Site Mitigation for Evaluation <br /> Vt I, REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/ ENIOR <br /> .ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FCR EVALUATION rES +0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> -VALUATOR SSQ �J <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />