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• SAN JOA%CUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTA%LTH DIVISION <br /> 1 <br /> LOST WORKSHEET FOR SITE CLOSURE EVALUATION q <br /> ,,.1L.,, ATE <br /> AME OF FACILITY St�botd V V, -hc� <br /> WEEPS CODE (pl <br /> DDRESS $ZO y\ „ , (CCL, <br /> ANK SIZE o�DDv UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? es o ermit k acilit Status Code ** <br /> Y oc.Soil/GW Coni es to <br /> umber of Tanks at facility Be of Tanks(if available)] <br /> ype of Tank Leel gl I ngl mal <br /> Ill. TANK HISTORY t <br /> Vemb,l 3.1.90 <br /> as Tank tested? as o ailed precision test es o <br /> If yes, give date(s) <br /> INSPECTION REPORT FOR <br /> as a repair made to the tank system? as No f yes, what uas repaired? <br /> as repair done under inspection? es o ere soil samples analyzed? es !o TXE PH-G PH-D b/EDB <br /> Ype of failure/discharge atastroph is long-term leakage verfill nk nown ther: <br /> IV, REMOVAL HISTORY (ATTACH R SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> ,oil Samples Received as 0 epth to Ground Water 30 of/Year <br /> (<(b'/p; verage Annual Precipitation = 4 10-25 <br /> -Site Wells) as 0 umber 8 Type Irr am ub <br /> istance to Welt(s) from Tank S core S core S core <br /> ft; ft; ft C 0 pts C pts C <br /> ' 0 if 0 if 0 _fPts <br /> Site Feature . Leaching Potential Analysis R ondition R onditi on R ondition <br /> E is met E is met E 's met <br /> inimum Depth to groundwater from the Soil Sample (feet) <br /> 30_15=1J5' >100 1-1 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) I G <br /> None Unknown resent <br /> verage Annual Precipitation (inches) <br /> xxxxx c10 9 10.25 xxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration a <br /> f Leachate (i.e., septic systems, water wells, ponds) 1 <br /> None 1 Unknown resent <br /> lnique site features: Recharge area, coarse soil, nearby wells. <br /> /] At least ore than <br /> xxxxx Nona —I one one <br /> COLUMN TOTALS>>>TOTAL POINTS (,O + 3 V <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or less <br /> MAXIMUM ALLOWABLE B•T-X•E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> 'ample Result: <br /> two AXIMUM ALLOWABLE TPH LEVELS (ppM) ASOLINE 1000 100 10 <br /> � �� TPH IESEL 10,000 1000 <br /> 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 LOT 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, score 0 points. <br /> \3 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o ��� �.S <br /> -ttK�e of +anitl vemova <br /> LL-1 ecommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation Epb O 5.t Qpb <br /> Vil. REVIEW EVALUATION . TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> E!!T <br /> STAFFFOR CLOSURE ES '0 EFERRED TO SITE MITIGATION . EVALUATION ES !0 <br /> ATE CLOSURE LETTER MAILED <br /> ' -7_Z711 <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />