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SAN JOA9UIC! PUBLIC HEALTH SERVICES/ENVIRONMENTALhL, r ~` '1VISION <br /> 1. UORXSHEET FOR SITE CLOSURE EVALUATION ATE5-G . q Z <br /> 4"' <br /> OF FACILITY r �tl,y f1� AP �0yV1fY11&51Cn (r. EEps COOS qcC 3 <br /> 1:Ss 52 U 3 �S t 'I Eye. �CuwtTANK Io <br /> TANK SIZE RNQ UEL TYPE <br /> 1I. GENERAL SITE HISTORY <br /> ` I <br /> Is permit current? es o ermit # acility status Code 5 oc.Soil/GH Can es o <br /> umber of Tanks at facility ge of Tanks(if available) Ufl1� ype of Tank tee{ Fbeg! ngI Dual <br /> 111. TANK HISTORY <br /> 'as Tank tested? es o I ailed precision test 7 fes o If yes, give date(s) <br /> Jas a repair made to the tank system? es No 11f yes, what was repaired? <br /> �s repair, done under inspection? es o ere soil samples analyzed? es 10 TXE PH-G 10 <br /> PH-0 I 1Pb/ED11 <br /> vpe of failure/discharge atastrophic long-term leakage verfitt nknown cher: <br /> Iv. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT :DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Ires 14 1 o epth to Ground Water gyp` of/Year Tn verage Annual Precipitation i= 4 0-25 <br /> Site Wells) es a umber & TypeI I Err am of <br /> S Score. 5 Score 5 core <br /> istance to We[{(s) from Tank ft; ft; ft C 10 pts C 9 pts CPCs <br /> Q if 0 if 0 f <br /> R ondition R condition R ondition <br /> Site Feature - Leaching Potential Analysis E is met . E is met E s met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None a Unknown 3,resent <br /> vcrage Annual Precipitation (inches) xxxx 00 9 10-25 xxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> inique site features: Recharge area, coarse soil, nearby welts. At Least lore than <br /> xxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS <br /> Sample Result: (8 i X OR l ) RANGE OF TOTAL POINTS 9 pts or more41 4$ pts 40 pts or less <br /> , <br /> T- q8 B T X E 3 i X = ` <br /> 0 M MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> ample Result: SOU NI: 1000 100 10 <br /> [MUM ALLOWABLE TAH LEVELS (PPM) <br /> ��Qll TPH IESEL 10,000 1000 100 <br /> COTNOTES: ***If documented soil and/or.ground 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., scare 0 points. If depth -5 ft., do not use tab{e. <br /> \2 If precipitation is a 40 inches, score 0 points. <br /> \3 Levels for BTXSE are not applicabte at a TPH concentration of 10 ppn (gasatine) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CCNCLUSION W <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Ycs X o <br /> M <br /> 2. Recommend Site Closure t <br /> es o X If Yes, Refer to Site Mitigation for Evatuatton C <br /> ` II. REVIEW EVALUATION - TO BE CCMPLETED 3Y A SUPERVISOR/SENIOR �! <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> °7= REFERRED / /_ 2l. ATE CLOSURE LETTER MAILED <br /> 4TWKSH 4 /900 I <br /> .so - i <br />