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SAN JOAGUI)TJHTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEiwfH DIVISION <br /> I• UGST WORKSHEET FOR SITE CLOSME EVALUATION ATE Z_ 7 <br /> OF FACILITY � � CODEll3_3 <br /> RETS //7 �, �f AMK IDR D J <br /> ANK SIZE / QOD. L TYPE <br /> 11, GENERAL SITE HISTORY <br /> S permit current? K it M ecility Status Coda .Soil/GW Cant as q <br /> r of Tanks at facility We of Tanks(if aveitable) ype of Tank teal 1 l I Dual <br /> Iii. TANK HISTORY <br /> s Tank tested? es o acted precision test ? es Igol If yes, give dates) <br /> Jas s repel mute to the tank system? as Na f yes, what was repaired? <br /> Jas repair done under inspection? es o re soil samples anstyzed7 esi10TXE PH-G PN-D EDB <br /> type of faiture/discharge tsstrophic torp-term Leakage fill cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> it Samples Received as a th to Ground Water 3o ef/Ysar ;$(� Versge Annum Precipitation11, <br /> 4 0-25 <br /> -Site Wetl(s) es r & Type Irr am <br /> S re S re S ore <br /> istance to Walt(s) from Tank ft; ft; ft C 0 pts C pts C pts <br /> 0 f 0 if 0 <br /> R ition R ition R dition <br /> Site Feature - Leaching Potential Analysis E s sac E is met E met <br /> iniaasa Depth to groundwater from the Soil Saapte (feet) 30-9s 2 10100 1-100 C) 25-SOU <br /> ractures in subsurfan (applies to foothilts or mountain areas) O None Unknown Present <br /> verage Arnuat Precipitation (inches) KXXXXX -CIO 9 10-25 KXXXXXX 26-40lg <br /> -Rada conduits which increase vertical migration <br /> f teachate (i.e., septic systams, water welts, ponds) !D None unknown resent <br /> ique site features: Recharge arta, coarse soil, nearby watts. At least then <br /> vyxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS 20 + j g + o <br /> SamipL* Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or Less <br /> 68-ql� <br /> ,/ B T Ix <br /> E B T X E <br /> X-= 1.ia5pp� PMIN UM ALLOWABLE B-T-X-E LEVELS (PAIL) 1 50 50 50 .3 3 1. 1. NA.0 <br /> Sampte Result: 1NE 1000 100 10 <br /> IMMALLOWABLE TPN LEVELS (PPM) <br /> N �} TPN tIESEL 10,000 1000 100 <br /> OOTNOTE$. ***If documented soil and/or ground water contamination is present, do not complete the teaching potential <br /> Contamintion List for soil or ground water.) <br /> U if s 10 �cnis <br /> nd < 25�. sco�repo�10s. <br /> If depth =5 ft., do not use table. <br /> a If preci a s <br /> .0 Levels for BTXZE are not applicable at a TPH concentratian of 10 ppm (gasoline) or 100 ppm (dieset). <br /> VI. STAFF RECOMEWATIOM/CONCIJSION , <br /> 1. Are BTX i E or TPH Concentration s Allowable Levels es f <br /> 2. Recawend Site Closurees If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALLtAT1ON - TO BE COMPLETED BY A SUPERVISOR/SEMIOR <br /> WITH STAFF RECOMMENDATION FOR CLOSURE ES EFENW TO SITE MITIGATION FOR EVALUATION S /J00 I <br /> ATE REFERM / / ATE CLOSURE LETTER MAILED <br /> OF <br /> VALUATOR <br /> EH 23 80 (LIGn1=K /90 <br />