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SAN JOA0U[N CCUN 0 <br /> 9LIC HEALTH SERVICES/ENVIRCNMENTAL HEALTH SION <br /> UG.. �RKSHEET FOR SITE CLOSURE EVALUATIGH AATE77 <br /> AHE OF FACILITY , SVEEPS CCOE P <br /> nORESS -fQ 7 D ANK 10 * _3 <br /> rANX SIZE ( UEL TYPE <br /> IT. GENERAL SITE HISTORY <br /> f9 <br /> Is permit current7es o ✓ ermit - aeitity Status Code oc.Sait/GV Cont es o <br /> uriber of Tanks at facility ge of Tanks(if available) ype of Tank Leel Fbrgl ngl Dual <br /> III. TANK HISTCRY / <br /> as Tank tested7 es a ailed precision test 7 es o �-'ird?7 <br /> f yes, give dates) f / <br /> as a repair made to the tank system? es No f yes, what was r <br /> 'as repair done under inspection? es o ere soil samples analyzed? es o TXE PH-G IPH-0 b/508 <br /> ype of failure/discharge atastrcphie long-term leakage verfill I kknown then: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Sail Samples Received es o epth to Ground ''rater 5o of/Year F6 verage Annual Precipitation = 4 0-25 <br /> -Site WeLL(s) es a umber g Type 11 r as vb <br /> S score S Score 5 core <br /> istance to Well(s) from Tank ft; ft; ft C 10 pts C 9 Pts C 5 Pts <br /> 0 if 0 if 0 if <br /> R audition R condit!on R zcrdition <br /> 61. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimuo Oepth to groundwater from the Soi! le tfeet) >104 1-TCO 25-50\1 <br /> ractures in subsurface (applies to foothills or tarn areas) None Unknown resent <br /> Average Annual Precipitation (inches) KXXXXX <10 9 SO-25 xxxxxxx 25-40\2 <br /> an-Hac'e conduits shich increase vertical migration <br /> F leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> pique site features: Recharge area, coarse sail, nearby wells. At x <br /> Leas: lore than <br /> xxx a one one <br /> CCLUHN TOTALS—TOTAL POINTS * �� <br /> ample Result: (8 T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 -'48._PCs 40 Pts or less <br /> 9 T I X I E B JT X E <br /> HAXIHLM ALLCUABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Resuit: ASOLINE 1000 100 10 <br /> AX]H.rM ALLOWABLE TPH LEVELS (PPM) <br /> TPH IES€L 10,000 1000 100 <br /> FOOTNOTES: "'If docunented soil and/or ground water Contamination is present, do not complete the teaching potential <br /> analysis. (i.e., site is currently an UGT Contamination List for soil or ground water.) <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. if depth <=5 It., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levets for 9TX&E are not applicabte at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECCd'4iE0ATICN/CONCLUSION C <br /> 1. Are 3TX 3 E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Re=m erd Site Closure 1Y <br /> es o ::�E[ <br /> f Yes, Refer to Site Mitigation for Evaluation ? <br /> VII, REVIEW EVALUATION - TO BE CCHPLETED BY A SUPERVISOR/SENIOR <br /> -CNC'JR ?VITA STAFF AECCMHEYOATION FOR CLOSURE ES 0 EFE,RREO T4 SITE MITICATICN FOR EVALUATION ES O <br /> ATE REiERRED l� f 1 / ATE CLOSURE LETTER .4A1LED f / <br /> FfaPE OF <br /> ;'lALUATCR <br /> EH 23 80 (LIGTS;XSHT)\5/90 <br />