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SAN JOAOUI*TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL NO DIVISION '/ <br /> 1, UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE Z^ I� 9Y' <br /> AME OF FACILITY WEEPS CODE /� Q <br /> DDRESS ANK ID # <br /> ANK SIZE /000 .,Q UEL TTPE (� <br /> 11. GENERAL SITE HISTORY •+ <br /> Is permit current? as o ermit # I IF acility Status Code IDOC SaiI/GW Cont f es o <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tank teel Fbrgl ngl Dual <br /> fit. TANK HISTORY <br /> as Tank tested? o If as o ailed precision test ? es yes, give date(s) <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> ms repair done under inspection? es o ere soil samples analyzed?TnE�n <br /> 10 TXE PH-G PH-0 b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verf ill then. <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 J& of/Year g 6 verage Annual Precipitation = 4 10-25 <br /> On-Site Wells) es I o I umber 8 Type Irr Om ub <br /> S core S Score S Score <br /> Distance to Wells) from Tank ft; ft; ft C 0 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R ondition R condition R ondi[ion <br /> i. Site Feature - Leaching Potential Analysis E s met E is met E is met <br /> inimum Depth to groundwater from the Soil Sade (feet) � -//' 9 >100 1.100 •j 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) /D None Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX <10 Axxxxxx 26.40\2 <br /> an-Made conduits which increase vertical migration ' <br /> resent <br /> leachate (i.e., septic systems, water wells, ponds) (G None Unknown resent <br /> )nique site features: Recharge area, coarse soil, nearby wells. At leas[ lore than <br /> xmx None /9 one I <br /> '/one <br /> COLUMN TOTALS>>>TOTAL POINTS Z(' * L ' -� 73 <br /> Sample Res t: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 4=_48_pts 40 pts or less <br /> B T X E <br /> 7. MAXIMUM ALLOWABLE B•T•X•E LEVELS (PPM) 1 SO 50 5 .3 .3 1. 1. NA\3 <br /> pie Result: pU ASOLINE 1000 100 10 <br /> q <br /> ID-1 AXIMUH ALLOWABLE TPH LEVELS (PPM) <br /> 9. / Tp 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 LIST 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 STXBE are not applicable at a TPM concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1• Are BTX 8 E or TPH Concentrations(> llowable Levels Yes o <br /> 2. Recommend Site Closure 1Yes I VI-01 If Yes, Refer to Site Mitigation for Evaluation <br /> V11. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <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 /> — <br /> EH 23 80 (UGTWKSHT)\ /90 <br /> EH 29 80 <br />