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SAN JOAODU'M COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL MLTH DIVISION <br /> I. UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE �= _ C <br /> AME OF FACILITY CC-h , 14. ECORD ID a `.J <br /> DRESS 3C I ANK 1D Y ?� _ <br /> ARK SIZE I 10160 L TYPE „0 <br /> ll. GENERAL SITE HISTORY v� <br /> Is permit current? es vo ermit I - acility Status Code oc.soil/GWCent es o <br /> umber of Tanks at facility ge of Tank(if available) ype of Tank Leel I 1Fbrgl ngl I Dual <br /> III. TANK HISTORY <br /> Was Tank tested? es ao ailed precision test ? as o If yes, give date(s) <br /> Was a repair made to the tank system? as No f yes, what was repaired7 <br /> Was repair done under inspection? ea o ere soil samples analyzed? es o TXE PH-G PH-0 b/EDB <br /> ' Type of failure/discharge atastrcphie long-term Leakage I verfill ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es o epth to Ground Water ef/Year veroge Annual Precipitation L= 4 0-25 <br /> -Site Wells) es I o Liber & Type I irr I oa <br /> S <br /> core S Score 5 core <br /> istance to WeMs) from Tank ft; ft; ft C 10 pts C 9 pts C pts <br /> 0 if 0 if 0 f <br /> R oldition R condition It ordition <br /> W. Site Feature - Leaching Potential Am Lysis E is met E is met E s met <br /> inimmm Depth to groundwater from the Soil Sample (feet) - >100 I 1-100 Q 25-501 <br /> .� <br /> Fractures in subsurface (applies to foothills or mountain areas) ! None Unknown resent <br /> verage Annual Precipitation (inches) xxxx <10 9 10-25 xxxx 26-40L <br /> an-Made conduits which increase vertical migration <br /> f Leachate (i.e., septic system, water wells, ponds) ° None Unknown resent <br /> pique site features: Recharge area, coarse soil, or wells. At Least ore than <br /> (Muncipal=>2000 ft; domestic=>500 ft; irr/agri cut turat�resent) None we one <br /> COLUMN TOTALS>»TOTAL POINTS /nj ' 1 ' - <br /> ample Result: (S T X OR E) RANGE OF TOTAL POINTS 9 pts Or more 41 - 48 pts 40 pts or Less <br /> B T X E <br /> MAX[MLI ALLGWABLE B-T-X-E LEVELS (PPM) 1 SO 50 50 .3 .3 17 1. NAL <br /> Sample Result: SOLINE 1000 100 10 <br /> A%IMUX ALLOWABLE TPH LEVELS (PPN) <br /> TPH 1ESEL 10,000 1000 100 <br /> FOOTNOTES: —If documented soil and/or ground water contamination is present, do not complete the Leaching potent <br /> analysis. Ci.e., site is currently on LOT Contamination List for soil or grand water.) <br /> 1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth m5 ft-, do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> L3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diese L). <br /> VI. STAFF RECOMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentraof os > Allowable levels Yes ( o <br /> 2. Recommend Site Closure es o [f Yes, Refer to Site Mitigation for Eva luatim <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES O EFERRED TO SITE MITIGATION FOR EVALUATION ES O <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/94 <br />