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/ SAN JOA* X)NTY PUBLIC HEALTH SERVICES/ENVIRONMENTA*";m DIVISION ATE �,-- <br /> / UST WORKSHEET FOR SITE CLOSURE EVALUATION �j - <br /> JAME OF FACILITY �4 . Yo y ] E����L� / ECORD ID1/4,, <br /> OGRESS /fz ANK ID $ I � 7 —D5 <br /> ANK SIZE ��(i.i' "t� 11EL TYPE .tjGl�.j.. <br /> II. GENERAL SITE HI57ORY ,e+ <br /> is permit current? es o ermit # - aciLity Status Code `�=% oc.Soi L/GW Cont es o <br /> umber of Tanks at facility S ge of Tank(if available) ype of Tank tee] Fbrgl ngl Dual <br /> [11. TANK HISTORY <br /> as Tank tested? es o ailed precision test ? es o If yes, give date(s) / / / / <br /> Pas a repair made to the tank system? es No f yes, what was repaired? <br /> ias repair done under inspection? es c ere soil samples analyzed? es o TXE PH-G PH-0 b/EDB <br /> T <br /> ype 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 o epth to Gror+d Water 5 0 of/Year ��j verage Amual Precipitation = 4 0-25 <br /> n-Site Wells) es I o I ud:er & Type Irr as 1. ub S core S Scare 5 3core <br /> istance to WeLI(s) from Tank ft; ft; ft C 0 pts C 9 pts C 5 pts <br /> 0 f 0 if 0 if <br /> R ondition R condition R ondition <br /> �J. Site Feature - Leaching Potential Analysis E s met E is met E is met <br /> Minimum Depth to groundwater from the Soil Sade (feet) <br /> >100 1-100 25-501 <br /> ' ractures in subsurface (applies to foothills or mountain areas) I None Unknown resent <br /> verage Annual Precipitation (inches) xxx -10 9 10-25 xxxx 26-40\2 <br /> I`4an-Made conduits which increase vertical migration t O More Unknown resent <br /> f Leachate (i.e., septic systems, water wells, ponds) <br /> At Least are than <br /> Unique site features: Recharge area, coarse soil, or wells. one one <br /> FMuncipal=>2000 ft; domestic=>500 ft; irr/agricuLtural=present] axxxx More <br /> COLUMN TOTALS»>TOTAL POINTS } <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or Less <br /> �i Q I B T X E B T X E <br /> 14AXIMU7 ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> am le RgSuIT:, <br /> $OLINE 1000 100 10 <br /> T�Y-� l� �c'l]')�J,' AXIMUN ALLOWABLE TPH LEVELS (PPN) 100 <br /> TPM fESEL 10,000 1000 <br /> OOTNOTES: ***If documented soil and/or grourd 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 c5 ft., do hot use table. <br /> \2 if precipitation is > 40 inches, score 0 points. ppm (gasoline) or 100 (diesel). <br /> \3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm <br /> VI. STAFF RECOMMENDATION/CONCLUSION I �DJ �(�/�{.L .CLA,16 L—/ <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes o Vim' x �to )�/ <br /> > Closure es o If Yes, Refer to Site Mitigation for Evaluation at ct-6- <br /> Recommend Site <br /> It. <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> e s: ' <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 />