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SAN JOAWLWNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL hffH DIVISION <br /> UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE S—3,. �75 <br /> AME OF FACILITY S F-eV ' ECORD ID I ) <br /> ADDRESS ANK ID # _ <br /> AGK SIZEUEL TYPE �/) / .JL <br /> 11. GENERAL SITE HIkohD /l/ff p <br /> S ORY 'V I <br /> w+ <br /> Is permit current? es o ermit # - acility Status Code ,- oc.Soil/GW Cont es o <br /> umber of Tanks at facility S Be of Tank(if available) <C 6 ype of Tank teeL Fbrgl ngl Dual <br /> 111. TANK HISTORY <br /> as Tank tested? es o ailed precision test ? as o If yes, give date(s) <br /> as a repair made to the tank system? Yes No 11f yes, what was repaired? <br /> as repair done under inspection? es 40 ere soil samples analyzed? as o TXE PH-G PH-0 b/EDB <br /> Type of failure/discharge atastrophic long-tenn leakage verfill noun ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil. Samples Received es I o epth to Ground Water 1,SL) of/Year g& ; verage Annual Precipitation A= 4 0-25 <br /> n-Site WeLL(S) es o umber & Type Irr an I ub <br /> S core S Score S 3core <br /> istance to WeIL(s) from Tank ft; ft; ft C 0 pts C 9 pts C 5 pts <br /> 0 f 0 if 0 if <br /> R ondition R condition R ondition <br /> V. Site Feature - Leaching Potential Analysis E 's met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 25-50L1 <br /> Fractures in subsurface (applies to foothills or mountain areas) I None Unknown resent <br /> Average Annual Precipitation (inches) xxxx <10 9 10-25 Kxxxxxx 26-4GL2 <br /> Ian-Made conduits which increase vertical migration <br /> Df Leachate (i.e., septic systems, water wells, ponds) C) 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) xxxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS A b + 191 - 5 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 /> n- D� Olt 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. NAL <br /> am le I;gsult- ASOLINE 1000 100 10 <br /> ft , LJ .� AXIMUM ALLOWABLE TPN LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> FOOTNOTES: •--If documented soil and/or ground water contamination is present, do not oomplete 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 /> V1. STAFF RECOMMENDATION/CONCLUSION4 <br /> 1. Are BTX & E or TPN Concentraentra tions > Allocable Levels Yes o 07. <br /> 2. Recommend Site Closure as Wo <br /> If Yes, Refer to Site Mitigation for EvaLuat ian <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR r ..U` ✓ (J`—`�/ <br /> ONCUR 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 />