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I <br /> SAN JOAOUI JNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL . H DIVISION �y <br /> I . UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br />' AME OF FACILITY p ozaECORD ID 3 <br /> ODRESS a ,5 ANK ID <br /> ANK SIZE �D. UQO UEL TYPE <br /> 11 . GENERAL SITE HISTORY <br /> Is permit current? es o ermit 9 - acility Status Code Ce�4 oc . Scil/GW Cont es o <br /> umber of Tanks at facility ge of Tank( if available) ld/ ype of Tank teel Fbrgl ngl Dual <br /> III , TANK HISTORY <br /> as Tank tag ted7 es o ailed precision test 7 es o jXjjf yes , give date( s ) <br /> as a repair made to the tank system? keg No x f yes , what was repaired? <br /> as repair done under inspection? es 40 ere soil samples analyzed7 es o I TXE I PH- G I PH -D I b/EDB <br /> ype of failure/discharge atastrophic long- term leakage verfill nknown then: <br /> IV . REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS ) <br /> oil Samples Received es X01 <br /> epth to Ground Water C} of/Year ; verage Annual Precipitation = 4 0 - 25 <br /> ii- Site Wells ) es o umber 8 Type Irr om ub <br /> S 3core S I scare 5 core <br /> is tance to We ( I ( s ) from Tank ft ; ft; ft C 10 pts C 9 pts C pts <br /> 0 if O if 0 f <br /> R monclition 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 - 50L <br /> Fractures in subsurface ( applies to foothills or mountain areas ) ) None Unknown resent <br /> verage Annual Precipitation ( inches ) xxxxxx <10 9 10- 25 xxxxmx 26- 401.2 <br /> an-Made conduits which increase vertical migration .� <br /> f leachate ( i . e . , septic systems , water we( ls , ponds ) U None Unknown 3resent <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 Mone <br /> rr one one <br /> COLUMN TOTALS»>TOTAL POINTS c'S (� <br /> } * O C� <br /> LeResult : ( 6 T % OR E ) RANGE OF TOTAL POINTS 9 pts or nate 41 - 48 pts pts or les/ V B 1 T X E B T % E <br /> MAXIMUM ALLOWABLE B - T- X -E LEVELS (PPM) 1 50 50 50 .3 .3 1 . 1 . NAL <br /> ample Result : ASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM ) j <br /> TPH IESEL 10, 000 1000 100 <br /> OOTNOTES : *** If documented soil and/or ground water contamination is present , do not complete the leaching potential <br /> analysis. ( i . e . , site is currently on UGT Contamination List for soil—orgromtvateC_ ) <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 BTXBE are not applicable at a TPH concentratim of 10 ppm ( gasoline) or 100 ppm (diesel ) . <br /> VI . STAFF RECOMMENDATION/CONCLUSION <br /> 1 . Are BTX 8 E or TPN Concentrations > Allowable Levels Yes 1 o <br /> 2 . Recommend Site Closure es o If Yes , Refer to Site Mitigat ' on for Evaluation TP HLJ 4� <br /> i <br /> VII . 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 / / C `� ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 ( UGTWKSHT ) \5/94 w 1 - <br />