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SAN JOAbUIiNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HH DIVISION <br /> I, UGST WORKSKEET FOR SITE CLOSURE EVALUATION ATE Z�Z ZZ <br /> AMS OF FACILITY " O WEEPS CODE Z <br /> DbRESS , rTANK ID # <br /> TANK 912E UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? 081 ko ermit p neility Status Coda oe.Soit/Gw Cont oa 0 <br /> umbar of Tanks at facility ge of Tonks(if available) ype of Tank teat Fbrgt1. ngl Dual <br /> Ill. TANK HISTORY <br /> ns Yank tested? Ives o ailed precision test 7 on o 111 yes, give date(s) / <br /> Jac a repair made to the tank system? es No f yes, what was repaired? <br /> ma repair done under inspection? es o ore soil sa+eptes analysed? es o P I-TXE PH-G PPD b/EDB <br /> ypo of failure/discharge atattrophic long-term leakage verfitl nknown ;her: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received as o epth to Ground Water of/Year C ve'age Annual Precipitationa 4 10.25 <br /> -Site Wall(&) es a I umber & Type Irr om ub <br /> - S Score S core S core <br /> lstance to Well(s) from Tank ft; -ft; ft C 10 pts C pts C pts <br /> 0 if 0 if 0 if <br /> R onditlon R ondition R ondition <br /> Site Feature • Leaching Potential Analysis E is mat E is met E Is met <br /> inimum bepth to groundwater from the Soil Sample (feet) 1,100 1.100 Q 25.50\1 <br /> roctures in subsurface (applies to foothills or mountain areas) None Unknown Drosent <br /> vorogo Annual Precipitation (inches) KXXXXX CIO 9 10-25 xxxxxxx 26.40\2 <br /> inn-mode conduits which increase vertical migration <br /> Df leachato (i.e., septic systems, water wells, ponds) f D None Unknown recant <br /> Inlque site footureas Recharge area, coarse soil, nearby wolfs; At least 40re than <br /> xxxxx None ono one <br /> COLUMN TOTALS»>TOTAL POINTS Z� + GI <br /> 3g <br /> Ample Results (B T >< OR t ) RANGE OF TOTAL POINTS 9 pts or more 41 . 48 pts 40 pts or less <br /> it T x E Br X E <br /> MAXIMUM ALLOWABLE D•Y-X=E LEVELS (PPM) 1 S8 50 SO .3 .3 1. 1- NA\3 <br /> "ampto Results ASDLINEj. <br /> 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH lESEL 10,000 1000 i00. <br /> oOTNOTESt *.cif documentod toll and/or ground water contarmination Is .presont, do not oomplete the leo <br /> analysis. (i.e., site is currently on UOT °Contamination List for coif or ground water.) <br /> \1 If depth is y 5 It. and a 25 ft., score 0 points'. If depth «5 ft., do not use table. <br /> \2 If precipitation is r 40 inches, score 0 points. <br /> \3 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1, STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are 0TX & E or TP H Concentrations ► Ailawablo Levels Yes 0 <br /> 2. Recommend Sita Closure es o If Yes, Refer to site Mitigation for Evatuatlon <br /> Vt14 REVIEW EVALUATION - To Be COMPLETED BY A SUPERVISOR/SENIOR <br /> .ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES O E!ERRED TO SITE MITIGATION FOR EVALUATION YES1 D <br /> ATE REFERRED % % ATE CLOSURE LETTER MAILED <br /> AME OF <br /> .VALUATOR <br /> EH 23 A00 (UGTWKSHT)\5/90 <br /> ZH 29 80 <br />