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SAN JOAOUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H DIVISION <br /> TVST WOWKKSHEET/FOR <br /> /SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY . <br /> ANK ID 0 7 <br /> rVl n v !_ItV �CiyyL ECORD ID <br /> 3 �- 7 <br /> '�' RO l —05 <br /> DRESS 6 <br /> ANK SIZE 55 4 UEL TYPE �tjyt,Z /`y <br /> it. GENERAL SITE HISTORY p J <br /> Is permit current? es o ermit X acility Status Code ! C oO.Soi UGW Cont es ° <br /> El <br /> umber of Tanks at facility <br /> S ge of Tank(if available) Ype of Tank Teel Fbrgt ngl Dual <br /> Ill. TANK HISTORY <br /> Was Tank tested? as o ailed precision test ? es o If yes, give dates) <br /> as a repair made co the tank system? as No f yes, what was repaired7 <br /> as repair done under inspection? es o ere soil samples analysed? es o TXE PH-G PH-0 WEDS <br /> ype of failure/discharge atastrophic Long-term Leakage verfill noun Sher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> of/Year //� verage Amual Precipitation = 4 0-25 <br /> oil Samples Received as o epth to Ground Nater ,h �(P % <br /> n-Site Wells) as I o I umber & Type I Irr am b <br /> S core S core S core <br /> istance to WeIL(S) from Tank ft; ft; ft C 0 pts C pts C _ Pts <br /> 0 f 0 if 0 f <br /> R onditim R ondition R ondition <br /> Site Feature - Leaching Potential Analysis E 's met E is met E S met <br /> M >100 1-100 25-50L <br /> inimum Depth to groundwater from the Soil SampLe (feet) <br /> None Unknown resent <br /> r,ctures in subsurface (applies to foothitLs or mountain areas) <br /> Peerage must Precipitation (inches) <br /> xxxx <10 9 10-25 xxxx 26-40\2 <br /> an-Made conduits which increase vertical migration ( O None Unknown resent <br /> f leachate (i-e., septic systems, water wells, ponds) <br /> At Least ore than <br /> nique site features: Recharge area, coarse SOIL, or wells. None one one <br /> (Muncipa L=>2000 it; domestic=>500 ft; irr/agricultural=present) <br /> a � s <br /> COLUMN TOTALS>» 1g 3TOTAL POINTS � <br /> ample Result: IS T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or Less <br /> X- D, QIP B T X E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NAL <br /> Tam (a p�tjpsult:f_ <br /> SOLINE 1000 100 10 <br /> rj y� � 77—J..� FAXIMUM ALLOWABLE TPH LEVELS (PPM)c'J100 <br /> TPH [ESEL 10,000 1000 <br /> OOTNOTES: --if documented soil and/or ground water contamination is present, do not crop Lete the leaching potential <br /> analysis- (i.e., site is currentLy on UGT Contamination List for soil or ground water.) <br /> L 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. <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 ^'•��w�`�'`yQ��;� (-`wl4t iL__' <br /> 1. Are BTX & E or TPN Concentrations > Allowable Levels Yes o `-T' x� �o <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation , e5. <br /> `III. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES —FFTEFERRED 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 />