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SAN ,IOAOUI /NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H DIVISION <br /> 1 . UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY p ECORD ID 367 <br /> DDRE SSR ANK ID # 3 5 /7 , 6 2 <br /> TANK SIZE ' O OD d UEL TYPE a . <br /> 11 . GENERAL SITE HISTORY <br /> Is permit current? es o ermit # - acility Status Code oc . Soil /Gw Cwt es o <br /> umber of Tanks at facility Be of Tank ( if available) ype of Tank teel Fbrgl ngl Dual <br /> III . TANK HISTORY <br /> as Tank tested? es X <br /> o ailed precision test 7 es 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 inspection? es No ere soil samples analyzed? es X o TXE PH- G I PH -O I b/EDB <br /> Type 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 /> oil Samples Received es 1,\4o I epth to Ground Water ; of/Yeaverage Annual Precipitation = 4 0- 25 <br /> n- Site WeLI ( s ) es o umber & Type Irr I oa ub <br /> S Scare 5 Score S core <br /> istance to WeLL ( s ) from Tank ft ; ft ; ft C 10 pts C 9 pts C pts <br /> 0 if 0 if 0 f <br /> R ondition R condition R andition <br /> V . 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- 50_\1 <br /> Fractures in subsurface ( applies to foothills or mountain areas ) None Unknown resent <br /> Average Arnual Precipitation ( inches ) xxxxxx <10 9 10 - 25 xxxxxxx 26-402 <br /> on-Made conduits which increase vertical migration <br /> f leachate ( i . e . , septic systems , water wells , ponds ) None Unknown resent <br /> pique site features : Recharge area , coarse sail , or wells . At least ore than <br /> (Muncipal => 2000 ft ; domestic=>500 ft ; irr/agricultural=present] xxxx None one one <br /> COLUMN TOTALS»> TOTAL POINTS + + <br /> Lamp:teResutt : ( B T X OR E ) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> B I TX E B T [ xi E <br /> MAXIML14 ALLOWABLE B - T- X-E LEVELS ( PPM ) 1 50 50 50 .3 .3 1 . 1 . NAL <br /> ample Result : ASOLINE 1000 100 10 <br /> rKj � ' I AXIMUM ALLOWABLE TPH LEVELS ( PPM) <br /> l'� TPH—D fESEL 10 , 000 1000 100 <br /> OOTNOTE S : *** 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 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 /> 1 . Are BTX & E or TPH Concentrations > Allowable Levels Yes o S S f > " <br /> 2 . Recommend Site Closure es o If Yes , Refer to Site Mitigation far Evaluation f H <br /> VII . REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/L AD SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES Lel 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER NAILED <br /> AME OF ' <br /> VALUATOR - � <br /> EH 23 80 (UGTWKSHT ) \5/94 <br />