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SAN JOACUIn �. NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA. DIVISION <br /> UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY I O ECORD ID /� <br /> rI ODRE55 I n ��> ANK 10 3 7 - <br /> ANK SIZE 900 tUEL TYPE D e I <br /> [ I . GEVERAL SITE HISTORY <br /> IIs permit current? es o emit 9 - acility Status Cade aa-SpiL/GW Cont es �lo <br /> Number of Tanks at facility pge of Tank( ifi available) rfype of Tank feel Fbrq! -ngl Dual <br /> ISI . TANK HISTORY <br /> Las Tank tested? eso ailed precision test 7 es o If yes , give date( s) <br /> as a repair made to the tank system? es I Ho f yes , what was repairedl <br /> Uas repair done under inspection? es �!a ere soil sanples analyzed? es �!o TXE I PH-G PH-0 b/EDB <br /> �fype of failure/discharge atastrophic ling-tens leakage I verfill I known ther: <br /> IV . REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> i6oil Samples Received es o epth to Ground Nater of/Year 8 verage Annual Precipitation = 4 0- 25 <br /> - Site Wells ) es I o umber & Type Irr om ub <br /> S core 5 core 5 core <br /> istance to WeLL ( s ) from Tank ft; ft; ft C 0 pts C pts C pts <br /> 0 f 0 if 0 if <br /> R ondition R it <br /> R o"Iti . <br /> ! . Site Feature - Leaching Potential Analysis E - s met E is met E his met <br /> iniznn Depth to groundwater from the SaiL Sample ( feet ) 30 .— a >100 I P1 - 100 I © 125-50\ 1 <br /> rractures in subsurface ( applies to foothills or mountain areas ) r None I Unknown Present <br /> Average Annual Precipitarion ( inches ) :axx <10 9 110- 25 xxxxzx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> f leachate ( i . e. , septic systems , water wells, ponds ) / D None Unknown bresent <br /> Unicue site features : Recharge area, coarse sail , or wells . At least I`�'ore than <br /> (Muncioal =>2000 ft; domestic=>500 ft; irr/agri cut rural=present) ( None 9 I one I one <br /> s Aa » av - O <br /> COLUMN TOTALS >TOTAL POINTS � <br /> Sample Result : (B X OR , E ) RANG'c OF TOTAL POINTS 9 pts or moreI 41 - 48 pis/ 40 pts or Less <br /> B T X E B 7 X E 1. <br /> MAXIMUH ALLOWABLE B-T-%-E LEVELS (PPM) 1 50 50 50 .3 .3 I1 . i . <br /> 3 HAL <br /> fn �aa A) Qes j O m�. Kms/ CLINE 1000 100 10 <br /> lK + OD (f AXIlg1M ALLOWABLE TPH LEVELS (PPM) <br /> IESEL 10 , 000 1000 100 <br /> OOTHOTES : ** If documented sail and/or ground water contamination is present , do not complete the learhi teatla-L� <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 pointsm if depth �5 ft . , do rot use table. <br /> \2 If precipitation is > 40 inches , score 0 points. <br /> \3 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 o Q <br /> 2 . Recommend Site Closure es o If Yes , Refer to Site Mitigation for Evaluation X 3 ' / 7 <br /> ( 7 <br /> VII . REVIEW EVALUATION TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES O EFERRED TO SITE MITIGATION FOR EVALUATION Es <br /> 0 <br /> ATE REFERRED / / DATE CLOSURE LETTER MAILER <br /> AMC OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT ) \5/94 <br />