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SAN JOAOU— RUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL ....._TH DIVISION <br /> [, UST WORKSHEET FOR SITE CLOSURE EVALUATION 1, <br /> ATE <br /> AME OF FACILITYL/Iqu kit— RECORD ID3 l �� <br /> DDRESS &� 1 (!�- 'S, EI L - 1�.1C�CJ TANK ID # <br /> TANK SIZE <br /> _,C,�. UEL TYPE <br /> (I. GENERAL SITE HISTORY <br /> Is permit current? eso ermit # acidity Status Cn--- �f� ,;:.Soil/GW Cont es o <br /> Number of Tanks at facility 3 ge of Tank(if available) ype of Tank teed f Fbrgl ngl I Dual <br /> III. TANK HISTORY <br /> as Tank tested? es ailed precision test ? es oIf yes, give dates) <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> Jas repair done under inspection? es I No ere soil samples analyzed? 1Yes 1 140 TXE PH-GI IT PH-D I 1Pb/EDB <br /> ype of failure/discharge atastrophic Long-term leakage verfill nknown ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es i/ o epth to Ground Water 7 of/Year verage Annual Precipitation = 4 0-25 <br /> n Site WeIL(s) es o umber & Type Irr I Icm ub <br /> S Score S Score S Score <br /> istance to Wells) from Tank I UU 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 ondition <br /> 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 j 25-50\1 <br /> 'Fractures in subsurface (applies to foothills or mountain areas) None Unknown Dresent <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40,2 <br /> an-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/agricut tural=present] xxxxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS /C�% + i �' + ( �. <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> --i" �� X <br /> L 6 T X E B T X E <br /> /< 45 S3 14 U MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1.' 1. NA_\3 <br /> [ample Result: SOLINE 1000 100 - 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> , •�(�L TPH 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 /> 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 TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION l '7"L) <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes v' o <br /> 2. Recommend Site Closure 1Y <br /> es o ✓ If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION 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 (UGTWKSHT)\5/94 <br />