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SAN JOAOU __ 1NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL 1 ..H DIVISION <br /> I . UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE 7 <br /> AME OF FACILITYI�E efZ ' ; CORD ID 3 , ',� <br /> ADDRESSJ ANK 10 # 3 - l 5 <br /> ANK SIZE © EL TYPE /� _ A \ G ` � 7 ' �1 <br /> II . GENERAL S [ E HISTORY <br /> is permit current? es o ermit # �, 3 - �a� acility Status Code oc . SoiL/GWCont es o <br /> umber of Tanks at facility ge of Tank( if available) ype of Tank teel X1brg111 ngl I Dual <br /> 111 , TANK HISTORY <br /> as Tank tested? as o ailed precision test ? as <br /> 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 inspecti onT Yes No ere soil samples analyzed? es o T%E PH- G PH-O b/E08 <br /> Type of failure/discharge atastrophic long- teen leakage verfilt 1known 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 Amuat Precipitation k= 4 0-25 <br /> On- Site WeIL ( s ) es I o umber & Type I Irr I on I ub <br /> S Score S Score S core <br /> istance to Wells ) from Tank ft ; ft; ft C 10 pts C 9 pts C pts <br /> 0 if 0 if 0 f <br /> R =ndition 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 <br /> Fractures in subsurface (applies to foothills or mountain areas ) p More Unknown resent <br /> %verage Annual Precipitation ( inches ) XMX <10 9 10- 25 Xxzxxx 26-40� <br /> Ian-Made conduits which increase vertical migration <br /> f leachate ( i . e. , septic systems , water wells , ponds ) b None Unknown resent <br /> pique site features : Recharge area , coarse sail , or wells . At Least _ ore than <br /> (Muncipal =>2000 it ; domestic=>500 ft ; irr/agricultural=present] xxxx More ane one <br /> COLUMN TOTALS>»TOTAL POINTS a O + + O <br /> ample Result : ( B T X OR E ) YYL RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or Less <br /> S u3 BzY&PP /n, x = 7 <br /> T = 3 & 0P '� B <br /> PH. MAXIMUM ALLOWABLE B- T-X-E LEVELS (PPM ) 1 50 50 50 .3 .3 1 . 111 NAL <br /> Sample Result : ASOLINE 1000 100 10 <br /> 7) ooppvn- TP'tG AXIDR)M ALLOWABLE TPH LEVELS (PPM) <br /> TPH Q IESEL 10 , 0110 1000 100 <br /> FOOTNOTES : *** If documented soil and/or ground water contamination is present , do not complete the Leachl Tat <br /> analysis. ( i . e. , site is currently on UGT Contamination List for soil or ground water . ) <br /> \11, 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 BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel ) . <br /> VI . STAFF RECOMMENDATION/CONCLUSION Hofs 0 �P.e a-o, q�l i �lP�o M Q a3fm <br /> 1 . Are BTX & E or TPH Concentrations > Allowable Levels Yes IX o I S a-a SA-Mp ►e �� Sff <br /> f X <br /> 2 . Recommend Site Closure esI Ixo if Yes , Refer to Site Mitigation for Evaluation _� gyp YNR <br /> 0 <br /> V11_ REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LE SENIOR E113 � fA D 019 41 <br /> CONCUR WITH STAFF RECOMMENDATION FOR LOSURE ES 0 1 EFERRED TO SITE MITIGATION FOR EVALUATION ES 70 <br /> ATE REFERRED (/� / / IkTE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 ( UGTWKSHT ) \5/94 <br />