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SAN JOAOUII JNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL I + , H DIVISION /1 . UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE 7 — 6 / r <br /> AME OF FACILITY p ECOID ID <br /> ADDRESS R - ANK ID ji <br /> TANK SIZE UEL TYPE �1j,; &z, %4, ? <br /> / / ' <br /> 11 , GENERAL SITE HISTORY -CX, tioGr_eWGA b <br /> Is permit current? esX o ermit M - acility Status Code oc - Soil/GW Cont es o <br /> umber of Tanks at facility �j ge of Tank ( if available) ype of Tank Leel Fbrgl ngl I Dual <br /> III , TANK HISTORY <br /> as Tank tested7 eso ailed precision test ? as o If yes , give date( s ) <br /> as a repair made to the tank system? as No f yes , what was repaired? <br /> Jas repair done under inspection? es o ere soil samples analyzed? as a I TXE I PH- G PH •D b/EDB <br /> Type of failure/discharge atastrophic Long- term leakage I verfill F nknown ther : <br /> IV . REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS ) <br /> oil samples Received es o epth to Ground Water of/Year verage Annual Precipitation 4 0- 25 <br /> )n- Site WeIL ( s ) as o umber 8 Type 11r as ub <br /> S core S Score 5 3core <br /> Distance to Wells ) 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 ond1ti on <br /> rniquee <br /> e Feature Leaching Potential Analysis E is met E is met E is met <br /> Depth to groundwater from the Soil Sample ( feet ) > 100 1 - 100 O 25 - 50)1 <br /> es in subsurface ( applies to foothills or mountain areas ) / 0 None Unknown resent <br /> Annual Precipitation ( inches ) XXMX < 10 9 10 -25 xxxxxx 26- 4012 <br /> e conduits which increase vertical migration <br /> hate ( i . e . , septic systems , water we( ls , ponds ) � � None Unknown resent <br /> site features : Recharge area , coarse soil , or wells . At least ore than <br /> pal => 2000 ft ; domestic=>500 ft ; irr/agricultural =present) Xx x More one one <br /> 5 - flCOLUMN TOTALS>>> TOTAL POINTS 0 V + + Q <br /> Result : ( 8 T % OR E ) 0 �1 RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or less <br /> 3 = f 7ipf� ; �� �Pprw B T X E B T X E <br /> _ y)'l. MAXIMUM ALL0WABLE B- T- X-E LEVELS (PPM) 1 50 50 SO . 3 . 3 1 . 1 - ( NAL <br /> ample Result : ASOLINE 1000 100 \ 10 <br /> (� ) D0O Paye. "� H C9- AXIMUM ALLOWABLE TPH LEVELS (PPM ) :: iF I <br /> (a TPH p IES 10, 000 1000 100 <br /> OOTNOTES : *** If documented soil and/or ground water contamination is present , do not complete the leeching <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 /> \201f 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 y� &aoL 3Cejopym . <br /> 1 . Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o I yl <br /> 2 . Recommend Site Closure es o <br /> If Yes , Refer to Site Mitigation for Evaluation ���� <br /> VII . REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES ) O EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT ) \5/94 <br />