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SAN JOAOUINY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE• DIVISION <br /> 1. ST WORKSHEET FOR SITE CLOSURE EVALUATION ATE Z <br /> AME OF FACILITY I Ip. , /- WEEPS CODE <br /> DRESS / Lir Y` i! " wy/� ' ANK ID X - <br /> TANK SIZE UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> N <br /> Is permit current? es o ermit 0 - aciLity Status Code oc.SoiL/GW Cont es o <br /> umber of Tanks at facility Be of Tanks(if available) ype of Tank teal Fbrgl ngl Dual <br /> 111. TANK HISTORY <br /> as Tank tested? as o ailed precision test 7 as o If yes, give date(s) <br /> Jas a repair made to the tank system? as No f yes, what was repaired? <br /> as repair done under inspection? es o ere soil samples analyzed? as o TXE PH-G PH-D b/EDB <br /> Type of failure/discharge atastrophic long-term leakage verfiLL noun 1 10 <br /> ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es o epth to Ground Nater , of/Year q verage Annual Precipitation = 4 0-25 <br /> -Site WeLL(s) es o umber & Type Irr am <br /> S score S Score 5 Score <br /> istance to WeIL(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R tondition R condition R ordition <br /> Site Feature - Leaching Potential Are lysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) 1; -_L; 1100 1-100 �� 25-50 1 <br /> ractures in subsurface (applies to foothills or mountain areas) None unknown resent <br /> verage Annual Precipitation (inches) Xxxx <10 9 10-25 26-40L <br /> an-Made conduits which increase vertical migration <br /> f Leachate (i.e., septic systems, water wells, ponds) More Unknown resent <br /> ique site features: Recharge area, coarse soil, nearby wells. At Least 4ore than <br /> KXXXXX None one one <br /> 1 � . <br /> COLUMN TOTALS»>TOTAL POINTS + + <br /> ample Result: (B TX(�l1OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> N10 w' J> MAXIMUM ALLOWABLE B.T-X-E LEVELS (PPM) B 50 S(1 50 .3 .3 1. 1. NAL <br /> ample Resu-�lt: OLINE 1000 100 10 <br /> '.� 1MUM ALLOWABLE TPX LEVELS (PPM) <br /> IESEL 10,000 1000 100 <br /> FOOTNOTES: •"If documented soil and/or grand water contamination is present, do not complete the Leaching potential <br /> are lysis. (i.e., site is currently on UGT Contamination List for soil or grand water.) <br /> 11. If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> L If precipitation is > 40 inches, score 0 points. <br /> L Levels for 8TX&E are not applicable at a TPM concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPM Concentration > Allowable Levels Yes o <br /> 2. Racammevd Site Closure es I o I If Yes, Refer to Site Mitigation for Evaluation <br /> Vll. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES FF—YEFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED 13ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />