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SAN JOAOUAWNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL *H DIVISION / <br /> UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY �'� f2SR U ' C '_ ELORD ID <br /> Ea3 <br /> *DRESS D7� � �J [TANK ID # 3y -r-J��,o�-►oar <br /> TANK SIZE IFUEL TYPE I 4,g;eAZe <br /> 11. GENERAL SITE HISTORY ✓ <br /> Is permit current? es o ermit # - aciLity Status Code oc.Soil/GW Cont es o <br /> umber of Tanks at facility 1 ge of Tank(if available) a 1(A-1 ype of Tank Leel Fbrgl ngl Dual <br /> 111. TANK HISTORY <br /> as Tank tested? es IX�o ailed precision test ? es o If yes, give date(s) <br /> as a repair made to the tank system? Yesi No I f yes, what was repaired? <br /> as repair done under inspection? es o ere soil samples analyzed? es I o I TXE PH-G PH-D I b/EDB <br /> Type of failure/discharge atastrophic long-tens leakage verfill known 10 <br /> ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es NA10epth to Ground Water 5 of/Year SJp ; verage Annual Precipitation k= 4 0-25 <br /> n-Site WeIL(s) es o umber 8 Type I 1rr I om I ub <br /> S Score S Score S 3core <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 /> Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) 50-5'z q >100 1-100 i5 25-50_\l <br /> Fractures in subsurface (applies to foothills or mountain areas) I O None Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 Kmxxxx 26-401 <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 ore than <br /> [MuncipaL=>2000 ft; domestic=>500 ft; irr/agricultural=present] Mx None 1 we one <br /> COLUMN TOTALS>>>TOTAL POINTS ✓ * I �/ / <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 19 pts or more 4 GB-pt-d_;. 40'pts or less <br /> 13-NO X r - Ob0 <br /> r_� •007 r-- -' BOO cS' B T X E 8 T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1- 1. I NAL <br /> ample Result: ASOLINE 1000 100 10 <br /> -rPI-O J(OTPH AXIMUM ALLOWABLE TPN LEVELS (PPM) IESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do no 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 /> L2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTX8E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION O,ff 4o( ^ -& e R <br /> t. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes X <br /> 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/LEAD SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 I EFERRED TO SITE MITIGATION FOR EVALUATION FS O <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/94 <br />