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SAN JOAOUlk%--INTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H, w DIVISION <br /> I. UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE c5 <br /> AME OF FACILITY �•r —� ECORD ID a 3 a3 i <br /> ANK ID # I a3 ' <br /> TANK SIZE V�� UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> re <br /> Is permit current? es o ermit # - aciII ty Status Code oc.Sol l/GW Cont es o <br /> umber of Tanks at facility y ge of Tank(if available) ype of Tank teel FbrgL I ngl I DuaL <br /> III. TANK HISTORY <br /> Was Tank tested? es o 1 IF <br /> ailed precision test ? as o If yes, give date(s) <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> as repair done under inspection? es EFere soil samples analyzed? es o TXE PH-G PH-D b/EDB <br /> Type of fai Lure/discharge atastrophic long-term leakage verfill noun they. <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 //Ll of/Year FG verage Annual Precipitation = 4 0-25 <br /> n-Site WeLL(s) es o umber 8 Type Irr I am I ub <br /> S Score S core S core <br /> Distance to WeLI(s) from Tank ft; ft; ft C 0 pts C pts C pts <br /> 0 if 0 1f 0 if <br /> R ondition R ondition R ondi tion <br /> 1. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet)//1'-746 to >100 AL 51-100 25-501 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) uxux <10 9 10-25 KMX.X 26-40L <br /> Ian-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] xxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> T X E 8 T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (P 1 50 50 50 .3 1. 1. NA_\3 <br /> ample Result: ASO INE 1000 100 10 <br /> A Jf I✓Y IIAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH IE L 10,000 1000 100 <br /> oOTNOTES: ...if documented soil and/or ground water comas �a present o not complete the leaching potential <br /> analysis. (i.e., site is currently on UGT Lon � n 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 BTX8E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION Le&,qL P& S s c!• S' �ry <br /> 1. Are BTX 8 E or TPN Concentrations > Allowable Levels Yes o /JL&ef <br /> 2. Recommend Site Closure as o If Yes, Refer to Site Mitigation for Evaluation -s-& F, le- Lo&,- =5,� <br /> >r1l <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFEFIRED TO SITE MITIGATION FOR EVALUATION ES I INO <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED / / <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/94 `w <br />