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SAN JOAOUINIINTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HOH DIVISION <br /> 1. LOST WORKSHEET FOR SITE CLOSURE EVALUATION ATE I 21,1111Z. <br /> AME OF FACILITY VA." &-Aiv 44949-b(61-- EEPS CODE 1 70,E <br /> DDRESS D W Ave ITANK ID # y <br /> TANK SIZE UEL TYPE <br /> L';ULA2 <br /> 11. GENERAL SITE HISTORY <br /> ** <br /> Is permit current? es o ermit # acility Status Code oc.Soil/GW Cont es EUI <br /> umber of Tanks at facility ge of Tanks(if available) /t// ype of Tank test Fbrgl ngl Dual <br /> 111. TANK HISTORY <br /> Was Tank tested? esI/< Ilo ailed precision test ? as o If yes, give dates) <br /> Was a repair made to the tank system? as No f yes, what was repaired? <br /> ns repair done under inspection? es o ere soil samples analyzed? as to TXE PH-G PH-D b/EDB <br /> Type of failure/discharge atastrophic Long-term leakage verfill nknown I 4tler: <br /> IV, REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> ,oil Samples Received ITes I Ilol epth to Ground Water of/Year Eq rb; veroge Annual Precipitation = 4 10.25 <br /> 3n-Site Wells) es I o umber 8 Type I Irr I om ub <br /> S Score S core 5 5core <br /> istance to Wel l(s) from Tank ft; ft; ft 10 pts C pts C 5 pts <br /> 0 if 0 if 0 if <br /> R onditi on R ondition 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) >100 1.100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) O None Unknown resent <br /> vcrage Annual Precipitation (inches) xxxxxx <10 9 10.25 Kxxxxxx 26-40\2 <br /> on-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 soil, nearby wells. At least lore than <br /> xxxx None0 one one <br /> COLUMN TOTALS»>TOTAL POINTS O + �? + S r q� <br /> ;nmpte Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or Less <br /> B T X E B X E <br /> MAXIMUM ALLOWABLE B•T-X-E LEVELS (PPM) 1 50 50 50 .3_[3 1. 1. NA\3 <br /> 'ample Ressul ta'e5+xT5 EE <br /> 1000 00 10 <br /> Nv 5'—A AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPN 0,000 1000 100 <br /> OOTNOTES: ***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 /> \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 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 TPN Concentrations > Allowable Levets Yeso � I CIND 5010 � .0 S <br /> We- OF <br /> Ar- Ab <br /> 2. Recommend Site Closure as o If Yes, Refer to Site Mitigatiat for Evaluation (�Ddl2— OR, '915 0401'4770N' <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES I V�O I EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / j I ATE CLOSURE LETTER MAILED <br /> AME OF <br /> -VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 V <br /> EH 29 80 <br />