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SAN JOAOUI4_TY PUBLIC HEALTH SERVICESA MVIROIBENTAL DIVISION <br /> 1. UST WORKSMEET FOR SITE CLOSURE EVALUATION ATE I LAI 1448 <br /> OF FACILITY (lj CQlO ID <br /> rANX <br /> SS l ANK ID <br /> SIZE r& 0ft X L TYPE <br /> Ii. GENERAL SITE HISTORY <br /> Is permit current? es o rmit 8 - ecility Status Code oc.sof l/Gw Cont es <br /> umber of Tanks at facility ge of Tank(if available) ype of Tank teel ( l Dual <br /> 111. TANK HISTORY <br /> s Tank tested? es o ailed precision test ? es o f Yes, give date(s) <br /> Jas a repair made to the tank system? as No f yes, what was repaired? <br /> Jas repair done under inspection? es o soil samples analyzed? es TXE I PH-G PH-0 /EDB <br /> ype of failure/discharge stastrophictong-term leakage ill I linknowl lother: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es epth to Ground water 1 S6 ef/Yemr •� verage Annual Precipitationkthan <br /> -Site Well(s) es o r A Type Irr am <br /> S re S core S <br /> istance to Wells) from Tank ft; ft; ft C 0 pts C pts C <br /> 0 f 0 'f 0 <br /> R ition R ition R <br /> Site Feature - Leaching Potential Analysis E s met E 's met E <br /> inimun Depth to groundwater from the Soil Sample (feet) >100 1-100 <br /> ractures in subsurface (applies to foothills or mountain areas) None q Unknown <br /> %verage Annual Precipitation (inches) <10 9 10-25 <br /> an-Made conduits which increase vertical, migration Cl <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown <br /> ique site features: Recharge was, coarse soil, or wells. At least <br /> [Muncipal=>2000 ft; domestic=>500 ft; irr/agriculturat*presant] None one one <br /> COLUMN TOTALS>>TOTAL POINTS + + <br /> le ResuLL• (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> ;Olye 8 T % E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 3 1. 1. NA,_U <br /> apple Result: INE 1000 100 10 <br /> IMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH d IESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the teaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> 11 If depth is > 5 ft. and < 25 ft., score 0 points. If depth -5 ft., do not use table. <br /> 12 If precipitation is > 40 inches, score 0 points. <br /> _q Levels for BTX9E are not applicable at s TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX i E or TPH Concentration > Atloweble Levels es <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> WITH STAFF RECOMMENDATION FOR CLOSURE ES EFERRED To SITE MITIGATION FOR EVALUATION S <br /> E <br /> FERRED / �j ATE CLOSURE LETTER MAILEDOR <br /> EH 23 80 (UGTWKSHT)\5/94 <br />