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E� SAN JOACU I jNTY PUBLIC HEALTH SERVICES/ENIQRONMENTAL HEALTH DIVISION <br /> UST WORKSHEET FOR SITE CLOSURE EVALUATION ATF <br /> v <br /> AME OF,IFACILITY IV6 qece,_ CORD ID <br /> DORESS I ANK to # <br /> TANK SIZE �v UEL TYPE] �J <br /> i <br /> if. GENERAL SITE HISTORY <br /> :k <br /> Is perm4t current? es �lo ermit M - aci icy Status Code 47 5 IDoc.soil/Gil Cant es o <br /> ' I <br /> Number of Tanks at facili ry ge of Tank(if available) type of Tank teel NAFbgt I -gT Dual <br /> [If. TANK HISTORY I <br /> I as Tank tested? es 1I0>daRed precision test ? les �0 If yes, give date(s) <br /> 'as a repair made to the tank system? es I No f yes, what was repaired? <br /> �.as repair done under inspection? es o dere soil samples anal ed? Yes �o TXE r PH-G PH-0 b/EDB <br /> Fype alfailure/discharge rastrophic X, <br /> ong-cema leakage verfitE n they: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DAA FOR LEACHING POTENTIAL ANALYSIS) <br /> soil Sa+Les Received les I �o bepth to Ground Nater ef/Year verage Annual Precipitation �= 4 �30-25 <br /> k� <br /> -sitef�Uell{s) es I a �lumixr & Type Irr cm <br /> S core S care S core <br /> istanceh to We(L(s) from Tank ft; ft; ft C 0 pts C 9 prs C 5 pts <br /> 4 0 if 0 if <br /> F onditicn R condition R ondition <br /> 7-77 <br /> t:. Site4 Feature - Leaching Potential Analysis s mer E is met 'c is met <br /> Minimum Deprh to groundwater from the Soil SampEe (feet) jd-JO =�,7 >100 ! 1-100 I 25-501 <br /> rac:ures in subsurface (applies to foothills or mountain areas) Mone Unknown resent <br /> verage 'fnnuaL Precipitation (inches) xxxx ( -10 9 10-25 xxxx 26-40L <br /> 'h <br /> Man-Made conduits which increase vertical migration <br /> of Leachate (i-a., septic sys=ems, water wells, ponds) j O None Unknown resent <br /> ,i. <br /> Unique site features: Recharge area, coarse soil, or wells. At Leastore than <br /> CmuncipaL=>2000 ft; domestic=>500 ft; irr/agriculturai=present] None I oneI _ <br /> ane <br /> :r <br /> 'k COLUMN TOTALS>>>TOTAL POINTS <br /> Sam Ie Result: (B T X OR �E3) RANGE OF TOTAL POINTS pts or more I 41 - 48 pts 40 pts or Less <br /> r-ri <br /> MAXIMUM ALLOWABLE B-T-X-£ LEEVELS (PPM) 75JO50 50 .3 .3 I i. 1. � HAS <br /> ample Result: SOLINE 1000 100 f 10 <br /> 0 m IMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> OOTNOTES: —If documented soil and/or ground water contamination is present, do not camiere the leaching potential <br /> analysis. (i.e., site is currently an UGT Contamination List for soil or ground water.) <br /> 1 If depth is > 5 ft. and < 25 ft., score 0 points. if depth C5 ft., do not use table. <br /> If precipitation is > 40 inches, score 4 points. <br /> _\3 Levels for STXBE are not applicable ax a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> STARECOMh1EN0ATiON/CONCLUSIOM 1,' Pi�CCGZ�f+��C94`C/ -' <br /> ^1. Are'IhBTX & E or TPH Concentrations > Allowable Levels Yes o ' co !JT �J�n <br /> i J. Recnmrend Site Closure e5 o It Yes, Refer to Site Mi ti a[ian for Evaluation �C(X.�� -`"" , � <br /> I. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> 4 <br /> ,^,NCUR WITH STAFF RECOMMENDATION FOR CLOSURE ESI �10 £PERKED TO SITE MiT]GATION FOR EVALUATION �1E5 �i0 <br /> r ! II <br /> PATE RE4ERRED I / / bATE CLOSURE LETTER MAILED <br /> ME OF <br /> IVALUATOR <br /> =H 23 a0 (UGTVKSHT)\5/94 <br /> ,ti <br />