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f. SAN JOA A)NTY PUBLIC HEALTH SERVICES/ENVI RONMENTAL�:(H DIVISION ATE J <br /> UST WRKSHEET FOR SITE CLOSURE EVALUATION <br /> AME OF FACT Lt TY A �,� S ERV / 1.. E ECORD ID � <br /> J ter- ANKID9 3G - jGG�-c5 <br /> ODRESS 6PO7- �, iL (�' /\ <br /> ANK SIZE UEL TYPE l�Lr-aCil+ —Z, <br /> 11, GENERAL SITE HISTORY <br /> Is permit current? es o ermit X - acility Status Code � oc.Soi l/GW Cont es o <br /> 11 <br /> umber of Tanks at facility ge of Tank(if avaiLabl e) GCr r yPe of Tank Leel Fbrgl ngl Dual <br /> III. TANK HISTORY <br /> Gas tank tested? es o ailed precision test ? es o If yes, give date(s) <br /> I <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> Gas repair done under inspection? es o ere soil same Les analyzed? es o TXE PH-G PH-D h/EDB <br /> ype of failure/discharge atastrophic Long-term Leakage I verfill known they: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> �OiL samples Received es o epth [o Ground dater 5(i of/Year /S�p verage AmuaL Precipitation = 4 0-25 <br /> n-Site WeLI(s) es o umber 8 Type Irr om S are S Score S 3core <br /> istance to WeLL(s) from Tank ft; ft; ft CO f pts C pts C pts <br /> 0 if 0 if <br /> R anditian R condition R condition <br /> ,i. Site Feature - Leaching Potential Analysis Es met E is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet) 53-'9= If >1U0 1-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) I L None Unknown resent <br /> Average Annual Precipitation (inches) xxxx <10 9 10-25 xxxxxx 26-40 _ <br /> an-Made conduits which increase vertical migration 1 F', None Unknown resent <br /> or Leachate (i.e-, septic systems, water welLs, ponds) V <br /> I <br /> pique site features: Recharge area, coarse soiL, or we LLs. At Least Aare than <br /> lMuncipal=>2000 ft; d0mestic=>500 ft; irr/agricultural=present] xxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS <br /> ample Result: (8 T X OR E) <br /> RANGE OF TOTAL POINTS 9 pts or more 4 40 pts or less <br /> j3=lU0 X X060 8 T X E B T XE <br /> l� .DOS r00 MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NAL <br /> ample Result: <br /> $OLINE 1000 100 10 <br /> TT <br /> /�TPH AXIMUM ALLOWABLE TPH LEVELS (PPM) 10,000 1 1000 100 <br /> fESEL <br /> COTNOTES: --if documented soil and/or ground water contamination is present, do noZ'ZonpLete'ihe Learhirg potential <br /> analysis. (i.e., site is currently an 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 /> L If precipitation is > 40 inches, score 0 points. ppm (gasoline) or 100 ppm (diesel). <br /> \3 Levels for BTXBE are not applicable at a TPH concentration of 10 <br /> V1. STAFF RECOMMENDATION/CONCLUSION Q,K-;L0 <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes x <br /> o ..� L i <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> V11. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 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 />