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fi SAN JQ"I NTY PUBLIC HEALTH SERVICES/ENVIROMMENTAL H" DIVISION <br /> 1. �[JGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> PAW <br /> 0/ FACILITY S EPS CODE 2 <br /> SS r —ako ur. ID 0 <br /> SIZE L TYPE �n ( '` <br /> Z CO <br /> It. GENERAL SITE HISTORY <br /> s pe!0Z <br /> t currant? 66 o reit 0 seitity Status Code oc.Soit/GW Cant as o <br /> f Tat fee ItIty ge of Taniks(if available) ype of Tank test pt ngl Dwl <br /> 111. TAMIL HISTORY <br /> Jos Tank tested? ss o at led precision test ? es f yes, give date(s) <br /> s repair made to the tank system? res No f yes, what was repaired? <br /> s repair done under inspection? to e soil samples analyzed? ss TXE I PH-G PI.0 EDB <br /> IType of falturo/discharge tastrophic Long-term leakage fill I kknown I thsr: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> it Samples Received as o th to Ground water of/Year vorage Amort Precipitationf., <br /> 4 0-25 <br /> Site Watt($) es o r i Type Urr as <br /> S ore S core S are <br /> is tame to Wttl(s) from Tank ft: ft: ft C 0 pts C pts C pts <br /> 0 f 0 if 0 <br /> R Waftion R condition R dition <br /> prin=,"tur*1, <br /> Feature - Lsaehing Potential Analysis E s met E is mac E met <br /> epth to groundwater from the Soil Sample (feet) 3100 1-100 25-5011 in subsurface (applies to foothills or mountain areas) None l Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX X10 9 10-25 Kxxxxxx 26.40_U <br /> 4an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) 1 V None Unknown resent- <br /> ique site features: Recharge area, coarse sail, nearby welts. At least a than <br /> None —r one ne <br /> 'o '] <br /> COLUMN TOTALB>»TOTAL POINTS + 7 + 0 <br /> e Rosuut�t: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or toss <br /> B T X E B T IX E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 SO 50 SO .3 3 <br /> �ampt* Result: INE 1000 100 10 <br /> NIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> OOTNOTES: 'if documented soil and/or ground water contamination is present, do not compteto the leaching potential - <br /> analysis. (i.s., site is currently on UGT Contamination List for soil or ground water.) <br /> 11 If depth is > S ft. and < 25 ft., scare 0 points. If depth "5 ft., do not use table. <br /> If precipitation is > 40 inches, score 0 points. <br /> Levels for BTX&E we not applicable at a TPN concentration of 10 ppm (gasotine) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION ,. <br /> I. Are BTX i E or TPM Concentration > Allowable Levels Tes o <br /> 2. Recommend Site Closure es if Yes. Refer to Site Mitigation for Evaluation <br /> VII. REVIEV EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> EATEREFERM <br /> TH STAFF RECOMMENDATION FOR CLOSURE ES EFERREO TO SITE MITIGATION FOR EVALUATION ES <br /> / / TE CLOSURE LETTER MAILED Gf% Vim'' d <br /> Ex 23 80 (UGTiSCSiIT)\5/90C��r le Cl Sdc <br />