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SAN JOAOUIm uOUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL h,...-IH DIVISION <br /> I, UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY <br /> I RECORD ID 3 rs(�2 <br /> OGRESS + \ C�'> �,� Uv1G—C\ TANK ID # <br /> TANK SIZE UEL TYPE <br /> II. GENERAL SITE HISTORY <br /> Is permit current? es o ermit acility Status Code Gj - SoiL/GW Cont es o <br /> Number of Tanks at facility ge of Tank(if available) k IT <br /> ype of Tank tee] Fbrgl ngl Dual <br /> III. TANK HISTORY <br /> as Tank tested? es . o ailed precision test ? es o ,i If yes, give date(s) <br /> as a repair made to the tank system? es No 11f yes, what was repaired? <br /> as repair done under inspection? es o ere soil samples analyzed? es o TXE PH-G PH-DI IP <br /> b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfill known they: <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 Hater of/Year verage Annual Precipitation = 4 0 25 <br /> n-Site Well s) es ✓ o umber & Type Irr I cm ub <br /> S core S Score S 3core <br /> Distance to Wells) from Tank _a;'U ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R condition R condition R zondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 +' 25-50L <br /> Fractures in subsurface Capplies to foothills or mountain areas) 1( None Unknown resent <br /> verage Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-4012, <br /> Ian-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> pique site features: Recharge area, coarse soil, or wells. At least ore than <br /> (MuncipaL=>2000 ft; domestic=>500 ft; irr/agricultural=present] xxxxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS <br /> amole Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or Less <br /> 61 <br /> i <br /> E If� 4c) MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) B 50 50 50 .3 .3 1. 1. NAL <br /> Sample Result: SOLINE 1000 100 - 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> Ji &-L'C) TPN IDIESEL 1 10,000 1000 100 <br /> FOOTNOTES: ** If documented soil and/or ground water contamination is present, do not complete the leaching potential <br /> 1 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., 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 BTX&E are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE CCMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE fES 0 EFERRED TO SITE MITIGATION FOR EVALUATION fES i 0 <br /> ATE REFERRED / L / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR c <br /> EH 23 80 (UGTWKSHT)\5/94 <br />