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SAN JOAOUI&NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL 0H DIVISION <br /> I' <br /> LOST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY4�3 A11-1 <br /> DEEPS CODE <br /> DDRESS ��'' <br /> , ANK ID # <br /> ANK S12E �oO� UEL TYPE f <br /> 11. GENERAL SITE HI <br /> xx <br /> Is permit current? es o ermft # acility Status Code oc.Soil/GW Cont os o <br /> umber of Tanks at facility ge of Tanks(if available) IType of Tank test brgl ngl Dual <br /> 111. TANK HISTORY <br /> as Tank tested? as a ailed precision test T es o If yes, give date(s) <br /> as a repair made to the tank system? es No f yes, what was repaired7 <br /> ns repair done under inspection? es o 14ere soft samples analyzed? 1Yas )o TXE PH•G PH-O b/EDB <br /> ype of failure/discharge atastrophic long-term leakage I laverfitt nkncwn I lather; <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Felt Samples Received es o epth to Ground Nater iVe/ of/Year �( ; �� verage Annual Precipitation = 4 10.25 <br /> )n-Site Wells) es0 umber 8 Type Irr an ub <br /> S Score S Score 5 3core <br /> (stance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C i pts <br /> 0 if 0 if 0 'f <br /> R ondition R conditf on R onditfon <br /> V. Site Feature - Leaching Potential Analysts E is met E is met E 's met <br /> inimum Depth to groundwater from the Soft Sample (feet) >100 1.100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None 17 Unknown resent <br /> verago Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> en-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> Inique site features: Recharge area, coarse soft, nearby wells. At least lore than <br /> xxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS `O ♦ a r e�-- T C7 <br /> ;7.Le Result: (S T X OR E) RANGE OF TOTAL POINTS 9 pts or more 1 48 pts 40 pts or Less <br /> .1\ � � �—IQP � B T % E B T X E <br /> K) t MAXIMUM ALLOWABLE S-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Semple Result: ASOLINE 1000 100 10 <br /> D <br /> s m A%(MUM ALLOWABLE TPH LEVELS (PP <br /> N D M) <br /> IESEL 10,000 1000 100 <br /> OOTNOTES: ***If documented soft and/or ground water contamination is present, do no plete 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 r5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes V I IA10 <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF q <br /> .VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />