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SAN JOAOUIKWTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H* DIVISION <br /> 1. UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY I __-f S I._ ECORD ID 2, <br /> 3 I6 ZI 7 <br /> ADDRESS �'D lb&7-0 <br /> TANK SIZE 100 UEL TYPE r�4Sf� <br /> ,��^, y �i'•� <br /> It. GENERAL SITE HI ORY <br /> M <br /> Is permit current? es o ermit # lFacitity Status Code oc.Soil/GW Cont as o <br /> umber of Tanks at facility lige of Tank(if available) ype of Tank FteeI Fbrgl I ngL I Dual <br /> III. TANK HISTORY <br /> as Tank tested? es o sited precision test ? as o If yes, give date(s) <br /> as a repair made to the tank system? as No f yes, what was repaired? <br /> as repair done under inspection? as oere soil samples analyzed? as o I TXE I PH-G I IrPH-DI b/EDB <br /> Type of failure/discharge atastrophic tong-tern Leakage verfiLl known they: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes o epth to Ground Water 5D of/Year S 6 ; verage Annual Precipitation = 4 0-25 <br /> 3n-Site WeLL(s) es o umber 8 Type Irr am ub <br /> S Score S core S core <br /> Distance to WeIL(S) from Tank ft; ft; ft C 10 pts C 9 pts C Pts <br /> 0 if 0 if 0 f <br /> R condition R condition R ondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E -s met <br /> inimum Depth to groundwater from the Soil Sample (feet)50-$=13� , >100 1-100 `5 25-50 1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> Average Annual Precipitation (inches) Xxxx <10 9 10-25 xxxxxx 26-402 <br /> Ian-Made conduits which increase vertical migration - <br /> f leachate (i.e., septic systems, water wells, ponds) ( O 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] xmx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS V I -� ! 3 <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or Less <br /> o SOD& X� *D _ 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 /> ample Result: P 10 d ASOLINE 1000 100 10 <br /> TP0p_ - I I AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> rr/n7 l7 TPH 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 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 BTXdE are not applicable at a TPH concentration of 10 PPM (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION my l tk Q p)„J�n ;� PA*I �pL <br /> 1. Are BTX 8 E or TPH Concentratio > Allowable Levels Yes o ^.&(,A)aa h Ie- If"a-r ^ <br /> 2. Recommend Site Closure as o If Yes, Refer to Site Mitigation far Evatuation /�qq bA,( L(sc �`Qe Sj/-AJ-(J �J <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR a' VI GK�� \3- 2;cA 6, <br /> CONCUR 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)\5/94 <br />