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SAN JOACUIX INTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE. -)IVISION <br /> ST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> ATE <br /> AME OF FACILITY �14�;i ECCRD ID <br /> OORESS 4i";Y < N ANK ID :I <br /> ANK SIZ_ O 1,,iJ UEL TYPE I <br /> II. GENERAL SITE HI`STORY <br /> is permit current? es �la emit - <br /> acility Status Code oc.S.il/GW Cont es �lo <br /> Number of Tanks at facility age of Tank(if available) Type of Tank teed brgl ngl Duall <br /> III. TANK HISTORY <br /> has Tank tested? es o ailed precision test ? Yes �Jo ( If yes, give date(s) <br /> Las a repair made to the tank system? es I No f yes, what was repaired? <br /> zs repair done under inspection? �tes �lo ( ere soil samples analyzed? Yes o , TXE I �PH-G PH-0 I b/EDB <br /> ype of failure/discharge atastrophic long-tern leakage overfill nl ther- <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received �es o pepth to Ground Water 45� of/Year 86 verage Annual Precipitation �t= 4 `10-25 <br /> Pn-Sito Wet L(s) es I �Io I umber & Type- Irr )cmI �b <br /> ( S core S core S core <br /> istance to WelL(s) from Tank ft; ft; ft C 0 pts C pts C pts <br /> 0 'f 0 if 0 f <br /> R cndition R ondition R ondition <br /> V. Site Feature - Leaching Potential Analysis E s met E is met E s met <br /> ,Minimum Depth to groundwater from the Soil Sample (feet) 3S I >100 I �51-100 I 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) ( None I Unknown I resent <br /> Average Annual Precipitation (inches) xxxx <10 9 110-25 26-4012 <br /> an-Made conduits which increase vertical migration <br /> i bf leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> PniGue site features: Recharge area, coarse soil, or wells. At least ore than <br /> (Mur.cipal=>2000 ft; domestic=>500 ft; irr/agricut tura l=present] KXXXXX None ( I one one <br /> I J <br /> COLUMN TOTALS»-TOTAL POINTS <br /> sample Result: (B T X OR =) RANGE OF TOTAL POINTS 9 pts or more ' 41 - 4a pt 40 pts or Less <br /> �= cZpe*"' --=/.)Wl? B T X EB T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 ( 50 50 I .3 l.3 1. 1. NAl3 <br /> ampple Result: LIRE 1000 100 10 <br /> N O- 41P101", TQC' IMUM ALLOWABLE TPH LEVELS (PPM) <br /> N•74!2= TPH-a- IDIESEL 1 10,000 I 1000 100 <br /> OOTNOTES: *—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 /> 11 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, score 0 points. <br /> 13 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> JI. STAFF RECOMMENDATION/CONCLUSION 'q' '40-7 —r-Irl) <br /> gy �. <br /> 1. Are BTX & E or TPH Concentrations > Allowable LevelsYes-x/ o Pb=Oy <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> VI;. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE fES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 l <br /> ATE REFERRED I / l / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR QCU <br /> -m 23 80 (UGTWKSHT)\5/94 <br />