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1, SAN JOI :OUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL LTH DIVISION <br /> e'er UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> AME OF FACILITY ATE ( -r <br /> -, sl <br /> DDRESS EEPS CODE <br /> ANK SIZE <br /> UEL TYPE ANK ID # <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? es o <br /> ermit # <br /> cumber of Tanks at facility acility Status Code oc.Soil/GW Cont es Io <br /> 9e of 7anks(if available) <br /> III. TANK HISTORY YPe of Tank Leel Fbrgl <br /> n9t Dual <br /> as Tank tested? es <br /> o ailed precision test ? <br /> es o <br /> as a repair made to the tank If Yes, sive dates) / / <br /> system? es No <br /> f Yes, what was repaired? <br /> as repair done under inspection? es <br /> o ere soil samples analyzed? es <br /> YPe of failure/dischar Io TXE <br /> 9e atastrophic tongPH-C PH-0 b/EDB <br /> -term leakage verfilt <br /> IV- REMOVAL HIS70RY (ATTACH INSPECTION R SPORT FOR nknown ther: <br /> SITE DETAILS/COLLECT DATA FOR LEACHIITG POTENTIAL ANALYSIS) <br /> .oil Samples Received es o _ <br /> epth to Ground Nater C of/Year <br /> -Site Nell(s) es - I verage Annual precipitation <br /> o umber 8 Type Irr = 4 10-25 <br /> istance to Wells) from Tank � ub <br /> — ft; „'_--ft; ---�—ft C core S core S <br /> 0 pts core <br /> i <br /> Site Feature 0 if 0 pts C pis <br /> Leaching Potential ondition R Anatysis R f 0 f <br /> R ondition R ondition <br /> inimum Depth to groundwater from the Soil Sample (feet) E is met E 's met <br /> E •s met <br /> ractures in subsurface (a >100 1 100 <br /> pplies to foothills or mountain areas) <br /> verage Annual Precipitation (inches) /t? None Unknown <br /> resent <br /> an-Made conduits which increase vertical xxxxx <10 9 10-25 <br /> f leachate (i.e., septic systems, migration xxxxxx 26-40\2 <br /> water wells <br /> ponds) <br /> Inique site features: Recharge area, coarse soil, nearby wells, None Unknown <br /> resent <br /> xxxxx None 4�7 At (eanst 40re than <br /> » TOTAL POINTS <br /> COLUMN TOTALS > oone <br /> '— <br /> ample Result: (S T X OR E) `' + _ + <� U <br /> RANGE OF TOTAL POINTS 9 pts or more <br /> V 41 <br /> 48 Pts 40 pts or tens <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (ppM) G T X E B T 50 <br /> SO X E <br /> -ample Result: •3 .3 1. 1. NA\3 �3 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) '�SOLINE 1000 <br /> r i%�1 TFH—U 100 10 <br /> oOTNO7ES: :�� IESEL 10,000 <br /> If documented soil and/or 1000 100 <br /> analysis. (i.e., site is urrentlywater nonmUGTCContamiion I's nationtList not or soil <br /> \7 If depth is > S ft. and < 25 ft., o'aplete the teaching potential <br /> \2 If is <br /> is > 40 inches, scorree00 points. If depth <_ °� ground water.) <br /> i3 Levels for 9TX8E are not a P -5 ft., do not—use use table. <br /> applicable at a TPHnconcentration of 10 <br /> STAFF RECOMMENDATION/CONCLUSION PPM (gasoline) or 100 <br /> PPm (diesel). <br /> i• <br /> Are BTX � <br /> 8 E or TPH Concentrations > Allowable i <br /> Levels Yes Io i ;3 �,q/ y <br /> 2• Recommend Site Closure �' •� -�'! <br /> es o If Yes, Refer to Site Mitigatia) for Evaluation <br /> t. REVIEW EVALUATION TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE 'ES '0 <br /> DATE REFERRED EFERRED TO SITE MITIGATION FOR EVALUATION ES <br /> ATE CLOSURE LETTER MAILED JO <br /> dAME OF �� <br />:VALUATOR <br /> H 23 80 (UGTNKSHT)\5/90 <br />:i 29 80 <br />