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SAN JOAOUI*NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL 10H DIVISION ATE a.3.y <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> 41 <br /> Z>j <br /> AME OF FACILITY �1/t,C'ncLe-t PUkLCL,[-I,C EEPS CODE t43g <br /> i�fi <br /> DDRESS `\2,(� W0.�to D ANK ID a <br /> TANK 512E UEL TYPE 02 oOpo*�40 g•L- 06- 350,5 1^)�5�' a <br /> 11. GENERAL SITE HISTORY 03 10,0000.0 U.L <br /> Is permit current? as o ermit k acility Status Code 0L7 oc.Soil/GW Cont es o <br /> umber of Tanks at facility CJ ge of Tanks(if available) ype of Tank teel brgl 1191 Dual <br /> 111. TANK HISTORY -�5 ra.mo✓ - -31-$x• <br /> 5 tome✓ 3.31.48 <br /> as Tank tested? es o ailed precision test ? as o f yes, give date(s) <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> die repair done under inspection7 as o ere soil samples analyzed? as Io TXE -G <br /> Typo of failure/discharge atastrophic long-term leakage verfill nknowr that: <br /> IV. REMOVAL HISTORY (ATTACH INSPECT ON REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es o epth to Ground Water �frJ of/Year I rverageual Precipitation 4 10.25 <br /> ype l Irr om ubScore 5 core <br /> istance to Wallis) from Tank mitic ft; ft; ft Cpts C pts <br /> 0if 0 if <br /> Ronditi on R ondition <br /> Site Feature . Leaching Potential Analysis Eis met E is met <br /> inimum Depth to groundwater from the Soil Semple (feet4 j— 12- -5 >100 1.100 t5 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) JZ) None Unknown rresent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10.25 xxxxxx 26.40\2 <br /> an-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 More than <br /> xxxxx None q one 15 one <br /> COLUMN TOTALS>>>TOTAL POINTS Mc) + t + 16 -34 <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> NQ . 2pptyi B T X E B T X E <br /> MAXIMUM ALLOWABLE B-T•X•E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> F <br /> -ample Result: ASOL(NE 1000 100 10 <br /> AXIMUM ALLOWABLE TPN LEVELS (PPM) <br /> N p I �APHM1PH IESEL 10,000 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 LOT 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 BTXSE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION PSD eUV&k✓LQ dDf C'0ntMry%k '=-r't \. <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes I INO \ <br /> 2. Recomnend Site Closure as jVjo I If Yes, Refer to Site Mitigation for Evaluation <br /> VI I. REVIEW EVALUATION . TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> .ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> -VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />