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SAN JOAC _JNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL ._ . .+H DIVISION C� <br /> 1 . UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE 7 � 6 <br /> AME OF FACILITY i r ECORD ID 3 <br /> lI DDRESS CQ ' ]TANK ID # - '1 5 <br /> 1 ANK SIZE © UEL TYPE <br /> XXff G 1 <br /> I 11 . GENERAL S1 E HISTORY <br /> Is permit current? es o ermit # ✓ - a5 acility Status CodeLQ� oc . Soi L/GW Cant es o <br /> umber of Tanks at facility �j ge of Tank( if available) >ao <br /> ype of Tank teel KlbrgL ngl Dual <br /> 111 , TANK HISTORY <br /> as Tank tested? es a ailed precision test ? es o If yes , give date( s) <br /> as a repair made to the tank system? es No f yes , what was repaired7 <br /> Jas repair done under inspection? es 1 . 40 ere soil samples analyzed? es o TXE PH- G PH-O b/EDB <br /> ype of failure/discharge atastrophic long-tern leakage verfill nknown ther: <br /> IV . REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS ) - <br /> Soil Samples Received es o epth to Ground Water of/Year Verage Annual Precipitation = 4 0-25 <br /> On- Site Well ( s ) es I o umber 8 Type Irr om Ub <br /> S Score S I Score S core <br /> ) istance to Wells ) from Tank ft; ft; ft C 10 pts C 9 pts C i pts <br /> 0 if O if 0 If <br /> R ondition R condition R ondition <br /> V . Site Feature - Leaching Potential Analysis E is met E is met E - s met <br /> inimum Depth to groundwater from the Soil Sample ( feet ) >100 1 - 100 ® 25-501.1 <br /> Fractures in subsurface (applies to foothills or mountain areas ) ' 0 None Unknown resent <br /> %verage Annual Precipitation ( inches ) axxxx <10 9 10-25 xxxxxxx 26-40L <br /> an-Made conduits which increase vertical migration p <br /> f Leachate ( i . e. , septic systems , water wells, ponds ) / b None Unknown resent <br /> pique site features : Recharge area, coarse soil , or wells . At leastore than <br /> (Muncipal =>2000 ft ; domestic=>500 ft ; irr/agricultural=present) xxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS a O, + + O dZ <br /> ample Result : (B T X OR E ) 0 rn RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> SrUj <br /> T = 360 P B T X E B T X E� <br /> Ili. MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1 . 1 NAL <br /> ample Result : rIESEL <br /> OLINE 1000 100 \ 10 <br /> 7,,Looff ` TPH G AXIMUM ALLOWABLE TPN LEVELS (PPM) <br /> TPH Q 10, 000 1000 \ 100 <br /> FOOTNOTES : *** If documented soil and/or ground water contamination is present , do not complete. the Leachi Ial <br /> analysis . ( i . e. , site is currently an UGT Contamination List for soil or ground water . ) <br /> \1 If depth is > 5 ft. and < 25 ft . , score 0 points. If depth <=5 ft . , do not use table. <br /> \2 If precipitation is > 40 inches , score 0 points . <br /> \3 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel ) . <br /> VI . STAFF RECOMMENDATION/CONCLUSION 46 0R. (SD �Jj0'� � / C,1010M <br /> 1 . Are BTX & E or TPN Concentrations > Allowable Levels Yes o ���[[.J/ sa-a Ed y {' _ <br /> 2 . Recommend Site Closure es o it Yes , Refer to Site Mitigation far Evaluation fJ� <br /> l `fb <j 1 <br /> VIL - REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/L5ffl SENIOR L:B s a D YN 0' r <br /> CONCUR WITH STAFF RECOMMENDATION FOR LOSURE ES 1001 <br /> EFERRED TO SITE MITIGATION FOR EVALUATION ES O <br /> ATE REFERREDG1 / / hTE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR ! <br /> EH 23 80 (UGTWKSHT ) \5/94 ' te� rai • ���, t <br />