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SAN JN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMEN*IEALTH DIVISION <br /> 1' <br /> LOST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> ATE <br /> AME OF FACILITY Al _ <br /> 14 le WEEPS CODE <br /> DRESS !� /�J ANK ID p <br /> 39 /SUS — <br /> ANK SIZE V.El TYPE <br /> I1. GENERAL SITE HISTORY <br /> Is permit current? as o <br /> ermit b acility Status Code 5 3 oc.Soi l/ -Cmc as - 0 <br /> unbar of Tanks at facilityll ge of Tanks(if available) <br /> ype of Tank teal Fbrgl Dual <br /> 111. TANK HISTORY <br /> as Tank tested? as o „ ailed precision test 7 es <br /> o If yes, give da[e(s) <br /> as a repair made to the tank system? as No i yes, what was repairedt <br /> as repair done under inspection? ea o ere soil samples analyzed? es o 77t <br /> ype of failure/discharge etas troph is Long-term leakage verfill nknown cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPEC N REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received as o epth to Ground Waterof/Year �' <br /> (p /1�,�� verage Annual Precipitation = 4 0-25 <br /> -Site Wells) as o umber 8 Type 9- Irr om ub <br /> istance to Wells) from Tank iG7V ft: ft. S core S core S core <br /> ft C '0 pts C pts C pts <br /> 0 f 0 f <br /> Site Feature - Leaching Potential Analysis R onditim R andi[ion R ordi[i on <br /> E is met E is met E 's nm[ <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 <br /> S zs-so,L1 <br /> ractures in subsurface (applies to foothills or mountain areas) <br /> None IT Unknown resent <br /> verage Annual Precipitation (inches) xmx <10 <br /> 9 10-25 xxxxxx 26-4012 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None <br /> Unknown 25� resent <br /> nique site features: Recharge area, coarse soil, nearby wells. <br /> At least / ore than <br /> xxxx None one I one <br /> COLUMN TOTALS>>>TOTAL POINTS + + - /S -S-3 <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or Less <br /> - U8 <br /> MAXIML14 ALLOWABLE B-T-X-E LEVELS (PPM) 150 50 50 .3 .3 1. 1. NAL <br /> ample Result: ASOLINE 1000 <br /> IMUM ALLOWABLE TPH LEVELS (PPM) 100 10 <br /> S TPH IESEL 10,000 1000 160 <br /> OOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the leaching <br /> analysis. (i.e., site is currently on LOT Contamination List for soil or ground waterr.)potential <br /> L If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> L If precipitation is > 40 inches, score 0 points. <br /> L Levels for BTXSE are not applicable at a TPM concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> V11. 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 /> ANE OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />