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SAN JOAWlh CODRTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HtM,*-a IVISION1. _ <br /> UST 1ARKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FA 011b <br /> ECORD ID <br /> DDRESS ANK ID # <br /> TANK SIZE UEL TYPE <br /> Il. GENERAL SITE HISTORY <br /> [s permit current? es o ,,\ ermit iFaciLity Status Code cc.Soit/GW Cont es o <br /> umber of Tanks at facility {ge of Tppank(if available) ype of Tank Leel Fbrgl ngl Dual <br /> III. TANK HISTORY - l'"1� )'l� 'r�V / 1 �.'1 " �; �L- /V <br /> Jas Tank tested? es o ailed precision test ?' es a If yes, give date(s) <br /> as a repair made to the tank system? Yes No f yes, what was repaired? <br /> Was repair done under inspection? es ere soil samples analyzed? es o TXE PH-G PH-0 b/EDB <br /> o <br /> _ Type of failure/discharge atastrophic long-terl leakage verfill noun ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received as - o epth to Ground Water knd <br /> of/Year11 verage Annual Precipitation = 4 045 <br /> )n-Site Well(s) es o I umber & Type Irr an ub <br /> " S core s Score S core <br /> istance to WeIL(s) from Tank ft; r_'fiLyj r. 4fs, ft C 10 pts C 9 pts C pts <br /> 0 if 0 if 0 f <br /> R ondition R condition It ondition <br /> V. 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 25-5011 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown .� resent <br /> verage Annual Precipitation (inches) xxxx <10 9 10-25 xxxx 26-40L <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> pique site features: Recharge area, coarse soil, or wells. At Least 4ore than <br /> (Muncipal=>2000 ft; domestic=>500 ft; irr/agricultural=present] x None (, we one <br /> COLUMN 70TALS>»TOTAL POINTS <br /> 1 <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> B T X E B T X E <br /> IJlf� MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1: 1. NAL <br /> Sample Result: rA - SOLINE 1000 100 (10 <br /> AXIMl1M ALLOWABLE TPH LEVELS (PPM) <br /> TPNIESEL 10,000 1000 100 1 <br /> FOOTNOTES: —`If documented soil and/or ground water contamination is present, do not complete the leeching 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 /> 12 if precipitation is > 40 inches, score 0 points. <br /> �3 Levels 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 Concentratio > AlLowable Levels Yes o <br /> 2. Reccimend Site Closure as �ho 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 ES 0 I EFERRED TO SITE MITIGATION FOR EVALUATION ES O <br /> ATE REFERRED ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/94 <br />