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LTH <br /> RONMENTAL <br /> SAN JOAW IN OTY <br /> GST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> HEM DIVISION ATE <br /> EVALUATION •�/ U <br /> 1• WEEPS CODE <br /> AME OF FACILITY mc'- /I ANK ID W <br /> DDRESS (Do 7 <br /> ANK S12E P UEL TYPE �' r <br /> II. GENERAL SITE HISTORY oc.Soil/GW Cont as ° <br /> Is permit current? es o <br /> acility Status Code <br /> ge of Tanks(if available) ype of Tank teal y Fbrgl <br /> umber of Tanks at facility ngl Dua <br /> III. TANK HISTORY <br /> as Tank tested? es o ailed precision test 7 es <br /> o If yes, give dates) <br /> No f yes, what was repaired? <br /> as a repair made to the tank systems as TXE PH-G PH-D b/EDB <br /> as repair done under inspection? as o ere soil samples analyzed? as ° <br /> ype of failure/discharge atastrophic long-term leakage verf ill nknown cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING vPOTENTIAL <br /> ANALYSIS) <br /> pitetion 4 0.25 <br /> al <br /> oil Samples Received as <br /> o epth to Ground Water J of/Year S ;17�. <br /> umber B Type Irr as ub s core S core <br /> n-Site Wells) es o S core <br /> ft C 0 pts C pts <br /> C <br /> ft; ft; 0 if 0 f pts <br /> istance to Wells) from Ten 0 if ondition <br /> R ondition R audition R -s met <br /> E is met E is met E <br /> Site Feature - Leeching Potential Analysis 1-100 5 25-50L <br /> >100 <br /> inimum Depth to grourdwoter frau the Soil Sample (feet) C, Unknown resent <br /> Wane <br /> ractures in subsurface (applies to foothills or mountain areas) 9 10-25 xxxxxx 26-402 <br /> xxxxx <10 <br /> verage Annual Precipitation (inches) <br /> an-Made conduits which increase vertical migration <br /> None Unknown 5_ resent <br /> f leachate (i.e., septic systems, water wells, Ponds) At leastore than <br /> usque site features: Recharge area, coarse soil, nearby wells. xxxxx None <br /> one 5 one <br /> /S <br /> COLUMN TOTALS»>TOTAL POINTS 6 40 [s or less <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts P <br /> B T X E B T X E <br /> /q �,�,,,, MAXIMUM ALLOWABLE B-T-K-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA O <br /> ASOLINE 1000 100 <br /> ample Result: AXIMUM ALLOWABLE TPH LEVELS (PPM) 1000 100 <br /> IESEL 10,000 <br /> TPH potential <br /> DOTNOTES: :'•(f documented soil and/ori teaisdcwater <br /> contamination on UGT ontaminationis tList for soil l oreground the ewaterr..)analys <br /> L If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> 40 idiesel). <br /> J2 If precipitation is > riches, score 0 points. <br /> �3_ Levels for BTXBE are not applicable at a TPH concentration of 10 (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX B E or TPH Concentrations > Allocable Levels Yes <br /> 0 <br /> es I rO IV If Yes, Refer to Site Mitigation for E <br /> 2. Recommend Site Closurevaluation <br /> V11. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR EFERRED TO SITE MITIGATION FOR EVALUATION ES O <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 <br /> ATE CLOSURE LETTER MAILED <br /> ATE REFERRED / / <br /> AME OF <br /> -VALUATOR <br /> EN 23 80 (UGTWKSHT)\5/90 <br />