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SAN JOAOLIINt iTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA. DIVISION <br /> ?. UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE 11C7116 W <br /> AME OF FACILITY ECORD ID <br /> circ.� <br /> a0RE55I �� 3^ ANK ID # <br /> w 14/1 ? <br /> AHK SIZE IFUEL TYPE .d t <br /> 11. GENERAL SITE HISTORY ` <br /> Is permit current? es �Eo ermit # - °l 1. acitity Status Code oc.Soil/GW Coria es I o <br /> Mumcer of Tanks at facility ge of Tank(if available) �Fype of Tank feel Fbrgi ngl Dual <br /> Ill. TANK HISTORY <br /> t+ <br /> as Tank tested? eso ailed precision test ? les o_ If yes, give dates) <br /> as a repair made to the tank system? es No f yes,.,what was repaired? <br /> Ws repair done under inspection? es !0 ere soil saiimles analyzed? Yes o I TXE I PH-G PH-0 I .�Pb/EDB <br /> Type of failure/discharge atastrophic I long-term leakage'4 verfiII own they: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received fes 0 epth to Ground Water of/Tear �; �� verage Amual Precipitation = �,4 0-25 <br /> pr.-Site WeLI(s) es a umber 8-Typeirr om Ei ub. <br /> ,;I, S core S � care S core <br /> ais.ance to Wells) from Tank ft; ft; rb; � ft C 0 pts C pts C pts <br /> 0 if 0 if 0 <br /> R ondition R condition R rdition <br /> H. Site Feature - Leaching Potential AnalysisE met E is met E .� met <br /> 6001 <br /> Minimum Depth to groundwater from the Soil Sample (feet) e \125-50Fractures in subsurface (applies to foothills or untai areNone resent <br /> verage Annual Precipitation ( ) xxxx 26-40\2 <br /> Man-Made conduits which incre se v �f <br /> g ion <br /> 6f leacnate (i.e., septic atlLs, ponds) None Unknown resent <br /> nicue site fe rut R ar r a , coarse soil, or a ls: At least are than <br /> IM:xcipal=>20 0 ft; s --500 ft; irr/agricut tural=p sent? x None I one one <br /> COLUMN TOTALS»>TOTAL POINTS 4 <br /> SamoLe Result: (B T X OR E) RANGE OF TOTAL, PO[NTS 9 pts or more 41 - 48 pts 40 pts or less <br /> I / (j 'b 8 T X E 6 T I T. 1. <br /> MAXIMLAi ALLOWABLE S-T-X-E LEVELS (PPM) 1 50 50 50 .3 3 NA13 <br /> ample Result: % �}-G SOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPMY; <br /> IESEL- 10,000 1000 100 .: <br /> OOTNOTES: '^rIf documented soil and/or ground water corstamination is present, do not complete the leaching potential <br /> analysis. (i.e., site is currentiy'on UGT.Gontamination List for soil or ground water..) <br /> L If depth is > 5 ft. and < 25 ft., score O.points: If depth. 5 ft., do rat use table. <br /> \2 If precipitation is > 40 inches, score O.points. <br /> \3 Levels for 3TX&1 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 > Allowable Levels Yes; <br /> VVV��� <br /> 2. Recommerd Site Closure es o 1f Yes, Refer to Site Mitigation for Evaluation <br /> vi 1. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SFNIOR <br /> ;,NCUR WITH STAFF RECOMMENDATION FOR CLOSURE YESLEFERRED TO SITE MITIGATION FOR EVALUATION ES 0 I <br /> ATE REFERRED Z/ / ATt CLOSURE LETTER MAILED <br /> AME CF L <br /> VALUATOR r V <br /> E' 23 80 (UGTWKSHT)\5/94 <br /> i; <br /> , sl <br />