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SAN JOAOUIJ "USLIC HEALTH SERVICES/ENVIRONMENTAL HEAT ISION <br /> (• UNP'WORKSNEET FOR SITE CLOSURE EVALUATION �"r ATE �S• <br /> AME Of FAC(Ll1Y <br /> SWEEPS CODE <br /> DDRESS S• <br /> TANK !D <br /> InNK SIZE 2 UEl TYPE — L <br /> 11. GENERAL SITE HISTORY <br /> i ** <br /> Is permit current? es o ermit if - acility Status Code oc.Soil/ Cont es C <br /> Weber of Tanks at facility Be of Tanks(if available) ype of Tank tee( brgt ngl Dual <br /> ill. TANK HISTORY <br /> as Tank tested7 es o ailed precision test 7 es I oIf yes, give date(s) /( <br /> as a repair made to the tank system? es Na f yes, chat was <br /> repaired? <br /> as repair done under inspection7 es No ere soil samples analyzed7 es o TX E PH-G PH-O %EDB <br /> ype of failure/discharge atastrophic long-term leakaerfill nknown they: <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 ?later 3o of/Year /9 j? (' verage Annual Precipitation = 4 0-25 <br /> -Site Well(s) es o unb F $ Trr cm ub <br /> S Score S coreS core <br /> istance to Welt(s) from Tank I ft; ft; ft C 10 pts C pts C i pts <br /> 0 if 0 if 0 "f <br /> R ondition R ondition R ondition <br /> Site Feature - Leaching Potential Analysis E is met E is met E s met <br /> inimun Depth to groundwater from the Soil Sample (feet) 3 O >100 1-100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) D None Unknown resent <br /> Average Annuat Precipitation (inches) KXXXXX <10 9 10-25 KXXxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) lV None Unknown resent <br /> pique site features: Recharge area, coarse soil, nearby welts. At least iore than <br /> xxxx None 9 one one <br /> COLUMN TOTALS>>>TOTAL POINTS 190 + <br /> ampte Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41'-"Apts 40 pts or less <br /> 31 5b <br /> BT X E B JT X E <br /> F 5- z MAXIMLIM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 5 .3 .3 1. 1. NA\3 <br /> ample Result: GASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, dolnt, complet a teaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for of 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 BTX8E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECCMMENDATION/CONCLUSION <br /> 1. Are BTX $ E or TPH Concentrations > Alto wa a Levels Yes o <br /> 2. Recommend Site Ctosure es o If Yes, Refer to Site Mitigation for Evaluation <br /> VI1. REVIEW EVALUATION - TO BE CCHPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECCHMENDATION FOR CLOSURE fES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED / / <br /> +AME OF <br /> :VALUATOR <br /> EH 23 80 (UGT"SHT)\5/90 <br />