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SAN JOAOL JNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL JH DIVISION <br /> 1 . UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE 7 � lo/ / r <br /> AME OF FACILITY A ) LqECORD IO 36 <br /> ADDRESS a $ ANK ID # 3 5 _ Q <br /> ANK SIZE O UEL TYPE LLti /1 <br /> II . GENERAL SITE HISTORY <br /> I <br /> Is permit current? eso ermit # - acility Status Code oc . Soil /GW Cont as o <br /> umber of Tanks at facility ] ge of Tank ( if available) ype of Tank teal Fbrgl ngl Dual <br /> i <br /> III . TANK HISTORY <br /> as Tank tested7 as 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 repaired7 <br /> as repair done under inspection? eso ere soil samples analyzed? as o TXE PH - G PH -D b/EDB <br /> ype of failure/discharge atastrophic long- term leakage verfill nknown they: <br /> IV . REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS ) <br /> Soil Samples Received as o epth to Ground Water of/Year verage Annual Precipitation A = 4 0- 25 <br /> n- site Wett ( s ) es o urber & Type Irr I oa ub <br /> S Score S core 5 Score <br /> istance to WeLL ( s ) from Tank ft; ft ; ft C 10 pts C pts C i pts <br /> 0 if 0 if 0 if <br /> R ondition R ondition 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 - 50L <br /> ractures in subsurface ( applies to foothills or mountain areas ) ; None Unknown resent <br /> verage Annual Precipitation ( inches ) xxxmx <10 9 10 -25 xxxxxx 26-402 <br /> Ian-Made conduits which increase vertical migration /} <br /> I leachate ( i . e . , septic systems , water we( ls , ponds ) / 0 None Unknown Dresent <br /> pique site features : Recharge area , coarse soil , or wells . At least ore than <br /> (MuncipaL => 2000 ft ; domestic=>500 ft ; irr/agricultural =present] xxxx None one one <br /> la— COLUMN TOTALS»> TOTAL POINTS �O + O C <br /> Sample Result : ( B T X OR E ) 7 , D In RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or less <br /> 5 -� 3 = ?ppm X = L <br /> T_::P n yy� a T x E B T X E <br /> MAXIMUM ALLOWABLE B- T- K-E LEVELS (PPM ) 1 50 50 50 .3 . 3 1 . 1 NAL <br /> ample ResuLt . ASOLINE 1000 100 \ 10 <br /> Lf, 7dplpp YN iTPH Q AXIMUM ALLOWABLE TPH LEVELS ( PPM )q ;l IESEL 10 , 000 1000 100 <br /> FOOTNOTES : *** If documented soil and/or ground water contamination is present , do not complete the leaching n ial <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 <=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 <br /> �.�-�-�y <br /> 1 . Are BTX & E or TPH Concentrations > Allowable Levels Yes o4.^..' �J u-IJ�J ) 1;1.(�Gt�✓'��Y/'0/�{��1'��5�,"��_ <br /> 2 . Recommend Site Closure as o If Yes , Refer to Site Mitigation for Evaluation " �-'• <br /> VII_ REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISO LEAD SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE E TjE`FERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / h / ATE CLOSURE LETTER RAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT ) \5/94 <br />