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SAN JOA0U1 . JNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL . H DIVISION <br /> I . UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE 7 , — 7 <br /> AME OF FACILITYI C' ECORD ID 3 5 <br /> DORESS Aa � ANK ID # 3 5 � _ /� <br /> L <br /> TANK SIZE �p6o0 tUEL TYPE vi � . , <br /> IT , GENERAL SITE HISTORY <br /> Is permit current? asIX o ermit 9 - aci ( ity Status Code 6;? cc . So WGW Cant es <br /> umber of Tanks at facility ] Be of Tank( if available) ILA '�J' ype of Tank Leel Fbrgl ngl Dual <br /> 111 , TANK HISTORY <br /> as Tank tested? as o ailed precision test 7 es o If yes , give date( s ) <br /> as a repair made to the tank system? es No x f yes , what was repaired? <br /> as repair done under inspecti an? es F 40 ere soil samples analyzed7 es a TXE I JE- G PN-0 b/EDB <br /> ype of failure/discharge atastrophic tong- tern leakage verfill known therm <br /> IV . REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS ) <br /> oil Samples Received es X o epth to Ground Water 0 of/Year _ verage Annual Precipitation = 4 0 - 25 <br /> n- Site Well ( s ) as o umber 8 Type 11 r cm I ub <br /> S core S core 5 core <br /> istance to Wells ) from Tank ft ; ft ; ft C 0 pts C pts C pts <br /> 0 if O if 0 f <br /> R ondition R onditian R ondition <br /> Site Feature - Leaching Potential Analysis E is met E is me[ E s met <br /> inimum Depth to groundwater from the Soil Sample ( feet ) > 100 1 - 100 25 - 50L <br /> ractures in subsurface ( applies to foothills or mountain areas ) None Unknown 3resent <br /> verage annual Precipitation ( inches ) 1(b <br /> <10 9 10-25 X%XMX 26- 4012 <br /> Ian-Made conduits which increase vertical migration <br /> f leachate ( i . e . , septic systems , water wells , ponds ) None Unknown resent <br /> pique site features : Recharge area , coarse soil , or wells . At least fare than <br /> (Muncipal => 2000 ft ; domestic=>500 ft ; irr/agricut tural =present] xxmx None one l one <br /> COLUMN TOTALS»>TOTAL POINTS It: + + O r <br /> ample Result : IS T X OR E ) RANGE OF TOTAL POINTS 9 pts or nate 41 - 48 pts /r.0 pts or les <br /> r *�� An 0 D B T X E B T X E <br /> MAXIMUM ALLOWABLE B - T-X-E LEVELS ( PPM ) 1 50 50 50 .3 .3 1 . 1 . NAL <br /> F <br /> ample Result : ASOLINE 1000 100 10 <br /> AXI MUM ALLOWABLE TPH LEVELS ( PPM ) <br /> TPH IESEL 1 10 , 000 1000 100 <br /> OOTNOTES : *** If documented soil and/or ground water contamination is present , do not ccmplete the leeching potential <br /> analysis . ( i . e. , site is currently on UGT Contamination List for so].l—orgram�xate[ ' ) <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 BTX8E are not applicable at a TPH concentration of"10 -ppm ( gasoline) or 100 ppm (diesel ) . <br /> VI . STAFF RECOMMENDATION/CONCLUSION / � —}. , S, 1 _Wp <br /> [ <br /> 1 . Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o Q�•blla tI / <br /> 2 . Recommend Site Closure es o If Yes , Refer to Site Mitigat ' on for Evaluation � P / <br /> V11 . REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/ EAD SENIOR / <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES O EFERRED TO SITE MITIGATION FO ATION ES _ <br /> ATE REFERRED G / / "' ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT ) \5/94 '4 1 - <br />