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SAN JOAOUINtIJUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HtNIN DIVISION <br /> I. LOST WORKSHEET FOR SITE CLOSURE EVALUATION ATE 3 - 3 <br /> AME OF FACILITY /� - WEEPS CODE , i S <br /> ADDRESS 331 11/7 Au oro ,S`�� ANK ID N a <br /> TANK SIZE 000 g,j UEL TYPE �ly, <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? o ermit p acility Status Code oc.Soil/GW Cont es <br /> Fes 70 <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tank Iiteel I IFbrgl I �ngl I Duall <br /> 111. TANK HISTORY <br /> as Tank tested? as ✓ o ailed precision test ? es 0 1 If yes, give date(s) <br /> as a repair made to the tank system? es No f yes, What was repaired7 <br /> ns repair done under inspection? ITas I No ere soil samples analyzed? es 7o TXE 17PH-G I PH-D b/ED0 <br /> ype of failure/discharge atastrophic long-term leakage verfill nknown 1 10cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received ITes Y/ o epth to Ground Water �Yof/Ycor I f q , 0 verage Annual Precipitation 4 10-25 <br /> )n-Site Welt(s) as o umber 8 Type Irr I cm I ub <br /> S Score S Score 5 Score <br /> istance to WeIL(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 PIS <br /> 0 if 0 if 0 if <br /> R ondition R condition R ondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1.100 S 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) V None Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 xxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> ! leachate (i.e., septic systems, water wells, ponds) Q None Unknown >resent <br /> lnique site features: Recharge area, coarse soil, nearby wells. q' At Least lore than <br /> xxxxx None one C /done <br /> COLUMN TOTALS»>TOTAL POINTS �0 i * 5 / <br /> ampule Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or Less <br /> �✓FV 0. t ,�� ,{��/,/ MAXIMUM ALLOWABLE D•T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> -ample Result: ASOLfNE 1000 100 10 <br /> N1e 0.f AXIMUM ALLOWABLE TPN LEVELS (PPM)+f n TPH IESEL 10,000 1000 100 <br /> OOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the Leaching potentia <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, score 0 points. <br /> \3 Levels for BTXBE are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION J <br /> 1- Are BTX 8 E or TPN Concentrations > Allowable Levels Yes I IN01 <br /> 2. Recommend Site Closure es I o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION • TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> .ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 70 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> Ex 29 80 / <br />