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SAN JOAOUINY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE DIVISION <br /> L ST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY U I 1 G WEEPS CODE <br /> DRESS ( J �� ,n ANK 10 # - <br /> TANK SI2E EL <br /> TYPE <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? es o ermit # iFacility Status Code oc.Soil/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) I IType of Tank Leel Fbrgl ngl Dual <br /> 111. TANK HISTORY <br /> Jas Tank tested? es o ailed precision test 7 es o If yes, give date(s) <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> Jas repair done under inspection? es o ere soil samples analyzed? es o TXE PH-G PH-D b/EDS <br /> Type of failure/discharge atastrophic Long-teem leakage verf t ll nam Cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es o epth to Ground water (!� of/Year �r ';J��, verage Annual Precipitation = 4 0-25 <br /> -Site Well(s) es o umber 8 Type Irr I am I b <br /> S core S core S 3core <br /> istance to WeIL(s) from Tank ft; ft; ft C 0 pts C pts C 5 pts <br /> 0 if 0 if 0 if <br /> R ondi tion R ondit ion R ondition <br /> 1. Site Feature - Leaching Potential Are lysis E s met E is met E is net <br /> inion Depth to groundwater from the Soil Sawte (feet), (/// , >100 1-100 �i 25-5011 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown Iresent <br /> verage Annual Precipitation (inches) xxxx <10 9 10-25 x 26-4012 <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 welts. At Least ore than <br /> xxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS * * <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or Less <br /> B T X E B T X E <br /> r KAXIML14 ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NAL3 <br /> ample Result: SOLINE 1000 100 10 <br /> " / //; IMUM ALLOWABLE TPM LEVELS (PPM) <br /> ��./ . / TPH IESEL 10,000 1000 f 100 <br /> FOOTNOTES: *"If documented soil and/or grand water contamination is present, do not complete the leaching potential <br /> analysis. (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 r_5 ft., do not use table. <br /> 12 If precipitation is > 40 inches, score 0 points. <br /> L Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> 4I. STAFF RECOMMENDATION/CONCLUSION ,�-�,/)•)� �'n��oul ,.,, •' <br /> 1. Are BTX 8 E or TPN Concentrati ons > ALLowable Levels Yes o /� <br /> 2. Recommend Site Closure es If Yes, Refer to Site Mitigation for Evaluation Gdi/l <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/ ENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES IV EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE L TTER ILED / <br /> AME OF <br /> VALUATOR <br /> EN 23 80 (UGTWKSHT)\5/90 <br />