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li <br /> ft y <br /> SAN .IOACUIA.- _WNT7 PUBLIC HEALTH SERVICES/ENVIRONMENTAL NEALrn DIVISION <br /> UST UORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> FACILITYI Q r 'tL/.�� 2EGOR0 III <br /> AMC OF 3 <br /> Cv <br /> ,F <br /> DDRSSS D J C/g/v! T, , �v <br /> —F <br /> IO <br /> 560 I <br /> TANK SIZF L TYPE <br /> !I. GENERAL SITE HISTORY <br /> [s permit current? es �lo e—it R - aci ity Status Cade oc.Soii/Gu Cont es a <br /> 4ffnner oT Tanks at facility Inge of Tank(if available) p'ype of Tank �teei Fbrgi ngE Dual j <br /> III. TANK HISTORY <br /> 'k <br /> as Tank,Itested? �tes tO ailed precision test ? les INO If yes, give date(s) <br /> 'as a repair made to the tank system? es No Xf yes, what was r fired? <br /> as repair done under inspection? es I �70� dere sail samples anal ed? es o TXE PH-G PH-O b/E08 <br /> ype a# failure/discharge I atastrophic fang-term leakage �verfi L I then: <br /> 'V. 2EMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DAT FOR LEACHING POTENTIAL ANALYSIS) <br /> ,F <br /> tai! Samples Received les a �epth to Ground Vater of/Year � ; verage ArnuaL Precipitation = F4 0-25 <br /> 4 <br /> n-Site WetL(s) IYes �o I dumber & Typel rr, cmI pub <br /> Score S Score S Score <br /> �istancalto VeLL(S) from Tank ft; ft; ft C 10 pts C P pis C pts <br /> if O if 0 <br /> i ondition A ondition R ondition <br /> Site�Feature - teaching Potential Analysis is met E is met - rs met <br /> M� p30— ?100 I �1-100 I O I25-50\1 <br /> Minimum Depth to groundwater iron the Sail Sample (feet) Y— t <br /> ,F <br /> Frac sures in subsur=ace (applies to foothills or mountain areas) INone I Unknown present <br /> rVerage hnnuat Precipitation (inches) o xxxx I <10 I 9 I10-25 xxxxxx zb-40\2 <br /> an-Made'Iconduits which increase vertical migration <br /> �r Leachate (i.e-, septic systems, water wells, ponds) None Unknown resent <br /> nicue site features: Recharge area, coarse soil, or wells. I4 At least ore than <br /> iMu^cipal=>2000 ft; domestic-500 ft; irr/agricut tura(=present) xxx ( None q one one <br /> i <br /> + C:.WMN TOTALS»>TOTAL POINTS <br /> oample Result: �(8 T X OR E) RANGE OF TOTAL POINTS pts ar mare 41 - 48 pts 40 pts or less , <br /> m T xE B T x E <br /> MAXIM ALLOWABLE B-T-X-E LEVELS (PPM) ( 50 1 50 15(1 I .3 �.3 � 1. 1. NA_ § <br /> �amole RFsul•i !_ SOLINE 1000 100 10 J <br /> f O� /fir SCS I -'7000 4AXIMUM ALLOWABLE TPH LEVELS (PPM) J <br /> s1i. IfSEL 10,000 1000 U 100 / <br /> :rOOTNOT-cC_ —If docanented soil and/or ground water contamination is present, do not complete the Leaching potential <br /> j 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., scare D points. If depth <=5 ft., do not use table. <br /> 12 If precipitation is > 40 inches, score 0 points. <br /> EF L Levels for 8TX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF R€COMMENDATION/CONCLUSION <br /> 1. AreIIBTX & c or TPH Concentrations > Ai(owabie Levels Yes o G� <br /> F <br /> 2. Recommend Site Closure es a If Yes, Refer to Site Mitigation for Evaluation <br /> h <br /> Vii. RSV Ifiu EVALUATION - TO SE CCMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> f <br /> BNCUR uITH STAFF RECOMMENDATION FOR CLOSURE �ES � �O EFERRED TO SITE MITIGATION FOR EVALUATION CES <br /> ATE R€'�;ZRED / (�1 PATE CLOSURE LETTER MAILED <br /> AME OF j+ <br /> VALUATOR <br /> i <br /> r <br /> cH 23 $0 (UGTWKSHT)\5/94 <br /> I <br />