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SAN JOAOUI&NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H4 DIVISION <br /> 1. UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY I ECORD ID /7 <br /> DRESS �e ANK IDX 3 - / -7.S- <br /> ANK SIZE UEL TYPE <br /> II. GEYERAL SITE HISTORY <br /> Is permit current? es o ermit # - acitity Status Code oc.Soi L/GW Cmt es T740 <br /> umber of Tanks at facility ge of Tank(if available) type of Tank tee? Fbrgl I IS <br /> ngL DuaL <br /> 111. TANK HISTORY <br /> as Tank tested? es o ailed precision test 7 es o If yes, give date(s) <br /> as a repair made to the tank system? es No Irf yes, what was repaired? <br /> as repair done under inspection? es No ere soil samples analyzed? es oTXE I PH-G irPH-D b/ED6 <br /> Type of failure/discharge atastrophic long-term leakage verfill noun I lother: <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 Water of/Year verage Annual Precipitation 4 0-25 <br /> On-Site WeLL(s) es o umber & Type Irr om ub <br /> S core S core S core <br /> istance to Wet L(s) from Tank ft; ft; ft C 0 pts C pis C <br /> Pts <br /> 0 f 0 if 0 f <br /> R ondition R ondition R oniftion <br /> Site Feature - Leaching Potential Analysis E s met E is met E 's met <br /> inimum Depth to groundwater from the Soil Sample (feet) 22_SD; 2�1 >100 I 1-100 ( Y 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) 0 None Unknown resent <br /> verage Annual Precipitation (inches) xxxx <10 9 110-25 mxxxx 26-4OL <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/agricultural=present] x//x''xx None 9 one one <br /> COLUMN TOTALS»>TOTAL POINTS /U + Ig + -7g( <br /> ample Result: (S T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or Less <br /> 1019 X B T X E 6 T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 X. <br /> E. <br /> NAS <br /> ample Result: SOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> 1✓D TPH IESEL 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 an UGT Cmtamination List for soil or ground water.) <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth c5 ft., do rat use table. <br /> \22 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 /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > ALLolIwable Levels Yes o <br /> I2. Recommend Site Closure �es I ryo IVIf Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BEII COMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES O <br /> )ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> E4 23 80 (UGTW SHT)\5/ 4 <br />