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SAN JOA OIl NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL If'H DIVISION <br /> "TT UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE 8—�I —Q.SJ <br /> - OF FACILITY e�,�et..(� _ i i C ECORD ID 2,3 <br /> DDRESS ! „s�s � w`✓l��v\( Ll � AMK ID <br /> ANK SIZE �(!CX-0 UEL TYPE ,U <br /> II. GENERAL SITE HISTORY �- ,cu / ,' ] IIaFtCle' <br /> Is permit current? es o ermit lFacility Status Code 9 9 « Soil/GW Cont as o <br /> umber of Tanks at facility , ge of Tank(if available) �� r ype of Tank teel Fbrgt ngl Dual <br /> 111. TANK HISTORY <br /> as Tank tested? es o ailed precision test ? es o / if yes, give date(s) <br /> as a repair made to the tank system? as No f yes, what was repaired? <br /> as repair done under inspection? 1yes <br /> F qo ere soil samples analyzed? es o TXE PH-G PH-D b/EDS <br /> Type of failure/discharge atastrophic long-term leakage verf ill nknown ther: <br /> IV. REMOVAL HISTORYJATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es o epth to Ground Water 4 of/Year 63 verage Annual Precipitation k= 4 0-25 <br /> On-Site Wells) es o 1 V/ umber & Type Irr I om I ub <br /> S Score S Score S core <br /> istance to Welts) from TankI AA ft; ft; ft C 10 pts C 9 pts C pts <br /> 0 if 0 if 0 f <br /> R condition R condition R ondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E 's met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 25-501 <br /> Fractures in subsurface (applies to foothills or mountain areas) V None Unknown resent <br /> verage Annual Precipitation (inches) xxxx <10 9 10-25 xmxmx 26-40L <br /> Ian-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) I None Unknown resent <br /> pique site features: Recharge area, coarse soil, or wells. At least lore than <br /> (Muncipal=>2000 ft; domestic=>500 ft; irr/agricultural=present] xxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS <br /> 9 <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> I� B T X E B T X E <br /> (\ti 'o MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NAL <br /> Sample Result: ASOLINE 1000 100 10 <br /> * t AX IMUM ALLOWABLE TPN LEVELS (PPM) <br /> `V�o TPH IDIESEL 1 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 /> \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 BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> V1I. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES (/t0 IZEFERREO TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED / / <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/94 • <br />