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SAN JOAOUITY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H (VISION <br /> T WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY � .r ECORD ID <br /> DDRESS I / W L ANK ID # <br /> TANK SIZE I O UEL TYPE <br /> I. GENERAL SITE HISTORY <br /> ** <br /> Is permit current? es o ermit # - acility Status Code oc.SoiL/GW Cont es <br />1I1 <br /> s o <br /> umber of Tanks at facility ge of Tank(if available) ype of Tank Leel Fbrgl I 1Sngt I Dual <br /> III. TANK HISTORY <br /> as Tank tested? es o ailed precision test 7 as o If yes, give date(s) <br /> as a repair made to the tank system? Yes No f yes, what was repaired7 <br /> as repair done under inspection? es o ere soil samples analyzed? Fes I o I TXE I PH-G I PH-D b/EDB <br /> Type of failure/discharge atastrophic Long-tena leakage verfiLl known ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received as o epth to Ground Water ef/Ye, I Fol verage Annual Precipitation = 4 0-25 <br /> On-Site WeLL(s) es o umber & Type Irr I am I ub <br /> S Score S Score S Score <br /> istance to WeLL(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R ondition R conditi on R ^ondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) Z 7, f' >100 1.100 3 25-50LI <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) xxxx <10 9 10-25 Kxxxxxx 26-401 <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, or wells. At least lore than <br /> (MuncipaL=>2000 ft; domestic=>500 ft; irr/agricultural=present) xxxx None '1 one one <br /> COLUMN TOTALS>>>TOTAL POINTS ' !�7 ' �D <br /> ample Result: (B TR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts <br /> O 4 or ess <br /> —/= B T X E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E1LEVELS (PPM) 1 50 50 50 <br /> ample Result: ASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> -Q. I-qLAI TPH —J;�­1 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 UGT Contamination List for soil or ground water.) <br /> L If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table- <br /> t 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 (diesel). <br /> 'I. STAFF RECOMMENDATION/CONCLUSION 7� <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes o <br /> Recommend Site Closure es 10 o I If Yes, Refer to Site Mitigation for EvaLuati on <br /> 'VIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> ? WITH STAFF RECOMMENDATION FOR CLOSURE ES"O EFERRED TO SITE MITIGATION FOR EVALUATION ES O <br /> FERRED / / ATE CLOSURE LETTER MAILED <br /> TWKSHT)\5/94 <br />