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SAN JOADUIh NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE. . DIVISION <br /> !. UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE 2 <br /> AME OF FACILITY I 11 l^ (p _ QNd ECORD ID I Z <br /> ODRESS I 1:21,p q ! l ` �11 s-f-- ANK ID # ?� <br /> TANK SIZE j'/OJ ff 1-ILL' UEL TYPE <br /> II. GENERAL SITE HISTORY <br /> Is permit current? es o ermit # - acility Status Code oc.Soil/GW Cont es o <br /> umber of Tanks at facility kge of Tank(if available) �fype of Tank tee[ I Fbrgl ngl Dual <br /> III. TANK HISTORY <br /> as Tank tested? es o ailed precision test ? Yes of If yes, give date(s) <br /> �as a repair made to the tank system? es No f yes, what was repaired? <br /> as repair done under inspection? esI �lo ere soil samples analyzed? es o TXE PH-G PH-D b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfill nown ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received fifes o epth to Ground Water of/Year ;$ verage Annual Precipitation = 4 0-25 <br /> i <br /> n-Site WeIL(s) es o umber & Type Irr am ub <br /> S Score S Score S 5core <br /> istance to WeLL(s) from Tank ft; ft; ft C 10 pts C 9 pts C <br /> pts <br /> 0 0 if 0 if <br /> R ondition R condition R ondition <br /> Site Feature - Leaching Potential Analysis E is met E is met E s met <br /> Minimum Depth to groundwater from the Soil Sample (feet) I >100 I 1-100 25-501 <br /> ractures in subsurface (applies to foothills or mountain areas) ( None Unkno ,sent <br /> Average Annual Precipitation (inches) xxxxf <10 I 9 - xxxx 26-4012, <br /> an-Made conduits which increase vertical migration <br /> f leacnate (i.e., septic systems, water wells, ponds) None �� U resent <br /> pique site features: Recharge area, coarse soil, or wells. At least 4ore than <br /> [Muncipal=>2000 ft; domestic=>500 ft; irr/agricut tura l=present] xxxxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS + I + <br /> Sample es4l: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more I 41 48 pts 40 pts or Less <br /> 'f- 'IZ pPrn B T X E B IT X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 11. NAL3 <br /> ample Result: SOLINE 1000 100 10 <br /> 'T"D H AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> 22,p� TPH I DIESEL 10,000 1000 100 <br /> OOTNOTES: *'*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 /> L If precipitation is > 40 inches, score 0 points. <br /> \33 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes C o <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> V11. REVIEW EVALUATION - TO BE CCMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> DATE REFERRED / / Ir ATE CLOSURE LETTER MAILED <br /> 1 i <br /> AME OF <br /> VALUATOR <br /> 1 <br /> EH 23 80 (UGTWKSHT)\5/94 <br />