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SAN JOAOUINTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL I6H DIVISION / �_�� <br /> 1. UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY :± k. Ss4R /' ECORD ID <br /> ADDRESS 'TV7� �/i� S I '0 L1,T(1�L� ANK ID # 3 - -7-0 <br /> TANK SIZE O UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> r* <br /> [s permit current? es o ermit # - acility Status Code oc.Soil/GW Cont IYeS o <br /> umber of Tanks at facility ge of Tank(if available) ype of Tank teel Fbrgl ngl I Dual <br /> 111. TANK HISTORY <br /> as Tank tested? es o IF ailed precision test ? as o If yes, give date(s) <br /> as a repair made to the tank system? as No f yes, what was repaired7 <br /> as repair done under inspection? es o ere soil samples analyzed? es o TXE PH-G PH-D b/EDB <br /> Type of failure/discharge atastrophic long-teen Leakage verfill nknown I i0thert <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received as o epth to Ground Water of/Year verage Annual Precipitation = 4 0-25 <br /> On-Site WeLI(S) es o umber & Type Irr an ub <br /> S Score S I Score S Score <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 ondition R condition R ondition <br /> v. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 25-50LI <br /> Fractures in subsurface (applies to foothills or mountain areas) More Unknown rresent <br /> Average Annual Precipitation (inches) uxmx <10 9 10-25 KMxmx 26-4OL <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> pique site features: Recharge area, coarse soil, or wells. At least 4ore than <br /> CMuncipal=>2000 ft; domestic=>500 ft; irr/agricultural=present) xxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS + + <br /> I r <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40tNA3or <br /> less <br /> T, 06,7 �n= , aaY <br /> • y B T X E 8 T X E <br /> Ol 1 /"' •� 1 MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. <br /> Sample Result: ASOLINE 1000 100 10 <br /> i r +11) PH AXIMUM ALLOWABLE TPH LEVELS (PPM) 1ESEL 10,000 7000 700 <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 ���-' C- <br /> 2. Recommend Site Closure as o If Yes, Refer to Site Mitigation for Evaluation r— <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR _ <br /> 7- <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES O EFERRED TO SITE MITIGATION FOR EVALUATION FS 0 rj B- <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/94 <br />