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SAN JOA011I11 C# PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALOIVISION ATE <br /> ,T WORKSHEET FOR SITE CLOSURE EVALUATION <br /> I. <br /> WEEPS CODE r) <br /> AME OF FACILITY <br /> f ANK 10 # ,r1�' <br /> DDRES5 <br /> 1ANK SIZE UEL TYPE _lCce- <br /> II. GENERAL SITE HISTORY <br /> current? es # <br /> .. acility Status Code "-)o x,5oi U GW Cont es <br /> Is permit o ermit a <br /> '7 a of Tanks(if available) ype� ype of lank feel Fhrg[ ngl Dual <br /> u,nber of Tanks at facility g <br /> Ill. TANK HISTORY <br /> o ailed precision test ? es o e <br /> If yes, give date(s) <br /> ns Tank tested? es <br /> as a repair made to the tank system? es No f yes, what was repaired7 <br /> as repair done under inspection? es a ere soil samples analyzed? es o TXE PH G PH D b/EDB <br /> ype of failure/discharge atastrophic long-term leakage <br /> verfill nknown then: <br /> 1V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> ait Samples Received es oEepth;toater � of/Year S�y ;�jl verage Annual Precipitation = 4 0-25 <br /> an ub <br /> -Site Wells) es o S core S core S core <br /> ft; ft C 0 pts C pts C pts <br /> istance to Wett(s) from Tank ft; 0 if 0 if 0 f <br /> R ondition R condition I Rs diition <br /> E is met E is met E <br /> met <br /> Site Feature - Leaching Potential Analysis <br /> inimun Depth to groundwater from the soil Sample (feet) 20_13� <br /> _�� >100 1-100 19 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) <br /> None Unknown resent <br /> xxxxx <10 4 10-25 xxxxxx 26-40\2 <br /> verage Annual Precipitation (inches) <br /> an-Made conduits which increase vertical migration Note Unknown resent <br /> f leachate (i.e., septic systems, water wells, ponds) <br /> At least are than <br /> 'nirque site features: Recharge area, coarse soil, nearby wells. one one <br /> xxxx None <br /> COLUMN TOTALS»>TOTAL POINTS 0 3 <br /> maple Result: (B T X OR E) <br /> RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> 03� �Z �is �( 8 T X E B T X E <br /> ��'2 .06Z-p .Ll;' pl'D MAXIMUM ALLOWABLE 8-1-X-E LEVELS <br /> ASOLINE 1000 100 14 <br /> ample Result: <br /> �`� r � AXI147H ALLOWABLE TPH LEVELS L. zESEL 10,000 1000 100 <br /> [/ TPH <br /> pOTNI Z TPH documented soil and/or ground water contamination is present, do not complete the leaching potential <br /> on UGT Contamination List for soil or ground water.) <br /> analysis. (i,e,, site is currently <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points, 1f 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 concentrat%on of 10 ppm (gasoline) or SOO ppm (diesel). <br /> 'll. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX E or TPH Concentrations > All able Levels Yes o <br /> 2. Recommend Site Closure es o if Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> )ATE REFERRED v / (�f/ 1 ATE CLOSURE LETTER MAILED % I <br /> SAME OF `, ,� <br /> :VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/40 <br />