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SAN JOAOUI / .NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H DIVISION <br /> I . UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE 7 - 6 <br /> — y <br /> AME OF FACILITY - 7 ECORD ID 3 <br /> 7d <br /> OD RE SS { lb It la cANK ID q131 5 —7 <br /> TANK SIZE 10) ot� UEL TYPE 'e <br /> 11 . GENERAL SITE HISTORY <br /> Is permit current? es o ermit N acility Status Code oc . Soil /Ow Cont es a <br /> umber of Tanks at facility ] Be of Tank ( if available) ype of Tank Leel Fbrgl ngI Dual <br /> I11 . TANK HISTORY <br /> as Tank tested? es 1k <br /> o ailed precision test 7 as o If yes , give date( s ) <br /> as a repair made to the tank system? es No f yes , what was repaired? <br /> as repair done under inspection7 as o ere soil samples analyzed? es a TXE PH- G PH- D b/EDB <br /> ype of failure/discharge atastrophic long- term leakage verfill known ther: <br /> IV . REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS ) <br /> Soil Samples Received es IX o I epth to Ground Water / 0 of/Year g6 verage Annual Precipitation = 4 0- 25 <br /> Dr - site WeLI ( s ) as o x umber 8 Type Irr cm I ub <br /> S core S Score 5 3care <br /> istance to WeLL ( s ) from Tank ft ; ft ; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R ondition R condition R ondition <br /> Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample ( feet ) > 100 1 - 100 25- 501 <br /> ractures in subsurface ( applies to foothills or mountain areas ) / None Unknown Dresent <br /> verage Annual Precipitation ( inches ) xxxmx < 10 9 10- 25 xmxmx 26- 402 <br /> Ian- Made conduits which increase vertical migration <br /> f leachate ( i . e . , septic systems , water wells , ponds ) / None Unknown resent <br /> nique site features : Recharge area , coarse soil , or wells . At least 4ore than <br /> (Muncipal => 2000 ft ; domestic=>500 ft ; irr/agricut tural=present] xxxmx None one one <br /> COLUMN TOTALS»>TOTAL POINTS c I� + + a <br /> ample Result : (B T X OR E ) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 <br /> 7l: �`S frll i� D <br /> 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 /> ample Result : ASOLI NE 1000 100 10 <br /> 1 V AXIMIIM ALLOWABLE TPN LEVELS (PPM ) <br /> III TPH ^ IESEL 10 , 000 1000 100 <br /> OOTNOTES : *** If documented soil and/or ground water contamination is present , do not complete the le king potenti <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 points. If depth 4=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 /> V1 . STAFF RECOMMENDATION/CONCLUSION <br /> 1 . Are BTX 8 E or TPH Concentrations > Allowable Levels Yes 01 1 <br /> 2 . Recommend Site Closure es o If Yes , Refer to Site Mitigation for EvaLuaiion. <br /> VII , REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR '---- - - <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ESO EFERRED TO SITE MITIGATION FOR EVALUA7I ON ES O <br /> ATE REFERRED / / �.i ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR � � - <br /> EH 23 80 (UGTWKSHT ) \5/94 <br />