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NAME OF FACILITY <br />ADDRESS <br />TANK SIZE <br />SAN JolkauloiNTY PUBLIC HEALTH SERVICIEVENVIRONMENTAL H DIVISION <br />LIST WORKSHEET FOR SITE CLOSURE EVALUATION 0 <br />ff U4IMVPWAM <br />permit current? �es I IN01 �ermit # I - acitity Status Code oc.Soil/GW Cont es <br />>er of Tanks at facility ge of Tank(if available) jtUN\F'. ype of Tank tee[I brgt it 0 F Frig t I Du <br />Jas Tank tested? �es �0 ailed precision test ? es o if yes, give date(s) <br />das a repair made to the tank system? Yes No f yes, what was repaired? <br />Jas repair done under inspection? les No Jere soil samples analyzed? - es 0 ETXE I t PH-GLLN-ILEEL <br />ype of failure/discharge I [atastrophic - Long-term Leakage L-EverfiLl �nknown I lother: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />SoiL Samples Received <br />es <br />I <br />IN01 <br />�epth to Ground Water I <br />of /Year <br />�verage Annual Precipitation <br />k= 4 <br />0-25 <br />On -Site WeLL(s) �es o umber & Type 1Irr om, I <br />Lub 1. <br />�eo <br />, <br />S ;core <br />S <br />Score Sc <br />)istance to Well(s) from Tank ft; - ft; ft <br />C 110 pts <br />C <br />9 pts C <br />5 <br />0 f <br />0 <br />if 0 <br />if <br />R ondition R <br />condition R <br />conditiorf <br />V. Site Feature - Leaching Potential Analysis <br />E is met <br />E <br />is met E <br />i s met <br />minimum Depth to groundwater from the Soil Sample (feet) <br />>100 <br />51-100 <br />25-5011 <br />Fractures in subsurface (applies to foothills or mountain areas) <br />None <br />Unknown <br />Dresent <br />Average Annual Precipitation (inches) xxxxxx <br /><10 <br />9 <br />10-25 xxxxxxx <br />26-40_\2 <br />4an-Made conduits which increase vertical migration <br />of Leachate (i.e., septic systems, water wells, ponds) <br />None <br />Unknown <br />DIresent <br />ipique site features: Recharge area, coarse soil, or wells. <br />At Least <br />4ore than <br />[MuncipaL=>2000 ft; domestic=>500 ft; irr/agricuLturat=present] Kxxxxx <br />None <br />one <br />one <br />- <br />COLUMN TOTALS>>>TOTAL POINTS I <br />+ <br />+ <br />I <br />Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more <br />41 48 pts 40 pts or less <br />meAl D <br />6045 13 1 T x8 <br />T XE <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) <br />1 1 50 1 50 1:0 <br />.3 3 1. 1. NA_\3 <br />.j <br />1 I I <br />Sample Result: ASMINE <br />1000 <br />100 10 <br />a.O:Fo Al4AXIMUM ALLOWABLE TPH LEVELS (PPM) <br />91 <br />-%lloom PHM) IESEL <br />11 <br />1=01000 <br />1000 100 <br />FOOTNOTES. ***If documented soil and/or ground water contamination is present, do not complete the teaching 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 <br />depth <=5 ft., do not use table. <br />L2 If precipitation is > 40 inches, score 0 points. <br />13Levels 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 <br />2. Recommend Site Closure es I E I If Yes, Refer to Site Mitigation for Evaluation <br />VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR <br />:ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE fES I �01 tEFERRED TO SITE MITIGATION FOR EVALUATION flES 0 <br />)ATE REFERRED )ATE CLOSURE LETTER MAI <br />4AME OF <br />EVALUATOR <br />EH 23 80 (UGTWKSHT)\5/94 <br />A7 <br />