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OF FACILITY <br />RANK SIZE I - bV`� <br />III. GENERAL SITE HISTORY <br />SAN JOAOUANTY PUBLIC HEALTH SERVICES/ENVIRONMENTALH DIVISION N. / <br />UST WORKSHEET FOR SITE CLOSURE EVALUATION AYE pO --(D <br />FECORD ID <br />ANK ID <br />'EL PE CAS, k.v.. <br />Is permit <br />current? <br />es <br />o <br />o <br />ailed precision test ? <br />ermit # <br />- <br />acility Status Code <br />=If <br />yes, give date(s) <br />oc. soi l/GW <br />Cont <br />AME OF <br />VALUATOR <br />as repair done under inspection? <br />o <br />FT <br />umber of <br />Tanks at <br />facility <br />Be of Tank(if available) <br />CANAU, <br />ype of Tank <br />tee[ I <br />VlFbrgi <br />atastrophic <br />ngl <br />Dual <br />verfill <br />III. TANK HISTORY <br />as Tank tested? <br />es <br />o <br />K <br />ailed precision test ? <br />as <br />I <br />k= <br />=If <br />yes, give date(s) <br />n -Site Well(s) <br />as a repair made to the to k system? es NOVA- f yes, what was repaired7 <br />AME OF <br />VALUATOR <br />as repair done under inspection? <br />as No <br />ere soil samples analyzed? <br />es <br />o I <br />TXE PH -G <br />PH -D <br />b/EDB <br />Type of failure/discharge <br />atastrophic <br />long-term leakage <br />verfill <br />nknown <br />Lher. <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />Soil Samples Received <br />es <br />o <br />ES <br />epth to Ground Wateret/Year <br />yLlI <br />verage Annual Precipitation <br />k= <br />4 <br />0-25 <br />n -Site Well(s) <br />es <br />AME OF <br />VALUATOR <br />o'14 <br />umber 8 Type <br />11 r <br />am I <br />u6 <br />S <br />C <br />core <br />10 pts <br />S Score <br />C <br />9 pts <br />S <br />C <br />Score <br />5 pts <br />istance to WeIL(s) from Tank <br />ft; ft; ft <br />0 <br />R <br />E <br />if <br />ondition <br />is met <br />O if <br />R condition <br />E is <br />met <br />0 <br />R <br />E <br />if <br />ondition <br />is met <br />V. Site Feature - Leaching Potential Analysis <br />inimum Depth to groundwater from the Sail Sample (feet) <br />>100 <br />1-100 <br />25-50_\1 <br />Fractures in subsurface (applies to foothills or mountain areas) <br />None <br />9 <br />Unknown <br />resent <br />verage Annual Precipitation (inches) <br />axmx <br /><10 <br />9 <br />10-25 <br />KMXXXX <br />26-40L <br />an -Made conduits which increase vertical migration <br />f leachate (i.e., septic systems, water wells, ponds) <br />ii <br />None <br />Unknown <br />resent <br />pique site features: Recharge area, coarse soil, or wells. <br />At least <br />4ore than <br />(Muncipal=>2000 ft; domestic=>500 ft; irr/agricultural=present] <br />Xx x <br />None <br />ane <br />one <br />`U <br />* <br />' * <br />S/ <br />y � <br />COLUMN TOTALS>>>TOTAL POINTS <br />ample Result: (B T X OR E) <br />RANGE OF TOTAL POINTS <br />9 pts or more <br />41 - 48 pts <br />40 pts or less <br />I� <br />B <br />T <br />X E <br />B <br />T <br />X E <br />U <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) <br />1 <br />50 <br />50 50 <br />.3 <br />.3 <br />1. 1. <br />NAL <br />ample Result: <br />SOLINE <br />1000 <br />100 - <br />10 <br />AXIMUM ALLOWABLE TPH LEVELS (PPM) <br />TPH <br />IESEL <br />10,000 <br />1000 <br />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 BTX8E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br />VI. STAFF RECOMMENDATION/CONCLUSION <br />1. Are BTX 3 E or TPH Concentrations > Allowable Levels Yes o <br />2. Recommend Site Closure as If Yes, Refer to Site Mitigation for Evaluation <br />VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR <br />CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE <br />ES I >CNO <br />I EFERRED TO SITE MITIGATION FOR EVALUATION <br />ES <br />O <br />ATE REFERRED <br />/ / <br />ATE CLOSURE LETTER MAILED <br />AME OF <br />VALUATOR <br />EH 23 80 (UGTWKSHT)\5/94 <br />