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SAN JOAOUI( PUBLIC HEALTH SERVICES/ENVIRONMENTAL "'IVISION <br /> I. WORKSHEET FOR SITE CLOSURE EVALUATION ATE 7J, (p ,q Z <br /> 4AE OF FACILITY : ►VA 20a v t h Ca L,rl COv"w+ss t LYI2 SWEEPS CODE X43 <br /> 'DDREss �j U 3 EaS�" Tr-o- � <br /> TANK ID <br /> TANK SIZE IOOO UEL TYPE Nj OL I <br /> II. GENERAL SITE HISTORY <br /> Is permit current? eso ermit At acility Status Code 5 oe.soil/GW Con es o <br /> umber of Tanks at facility 7J ge of Tanks(If available) U nK IType of Tank teet Fbrgl I ngt Dual <br /> III. TANK HISTORY <br /> 'as Tank tested? es I IN01 aited precision test ? es o If yes, give date(s) <br /> as a repair made to the tank system? Yes No f yes, what was repaired? <br /> as repair done under inspection? es o ere snit Samples analyzed? as 10 TXE PH-G I Y1,PH-0 I IPt/EOG <br /> ypa of failure/discharge atastrophic tang-term leakage verfil[ known ther: <br /> 1V, REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FGR LEACHING TENTIAL ANALYSIS) <br /> .oi( Samples Received es o epth to Ground Water rDi of/Year DoT"� verage Arcual Precipitation = 4 10-25 <br /> -Site Wells) es I a umber & Type I Irr San ub <br /> 5 core 5 core 5 Score <br /> istance to welt(s) from Tank €t; ft; ft C 0 pts C 9 pts C 5 pus <br /> 0 f 0 if 0 if <br /> R ondition R condition R ondition <br /> Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the SoiL Sample (feet) �p_ �' >100 1.100 25-50\1 <br /> ractures in subsurface (applies to Foothills or mountain areas) None Gf Unknown resent <br /> verage Annual Precipitation (inches) xxxx X10 9 10-25 xxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> of teachate (i.e., septic systems, water wells, ponds) None Unknown Oresent <br /> lnique site features: Recharge area, coarse soil, nearby wells. At Least lore than <br /> xxxx Hone one 5 one <br /> » <br /> COLUMN TOTALS 'TOTAL POINTS 7- 3 Z <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or .less <br /> 8- i0 <br /> T 410 B T X E B x MAXiMLO! ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 % .3 J.T <br /> 3 1. 1. NA\3 <br /> ample Result: SOLINE 1000 100 10 <br /> q �^ I" ALLOWABLE TAH LEVELS (PPM) <br /> `'t Do TPHPPm IESEL 10,000 1000 100 <br /> FOOTNOTES: Newif documented Bait and/or ground water contamination is prescnc, do not complete therleaching 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 <-5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, scare 0 points. <br /> \3 Levels for 9TX&E are not appticabte at a TPH concentration of 10 ppm (gasoline) or 100 ppm (dieset). <br /> VI. STAFF RECOMMENDATION/CONCLUSION Saw\ <br /> 1. Are BTX & E or TPH Concentrations > Attowabte LeveLs Yes o <br /> 2. Recommend Site Closure es a if Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> .ONCUR WITH STAFF RECOMMENOATIOH FOR CLOSURE VES1 0 EFERRED TO SITE MITIGATICN FOR EVALUATION ES 0 <br /> )ATE REFERRED / / �._.�- ATE CLOSURE LETTER MAILED <br /> IE OF <br /> '.UATOR <br /> 1 80 (UGTWKSHT)\SM <br /> '.9 80 <br /> J <br />