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SAN JOAOUffi`dJNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H.;I'H DIVISION <br /> UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY �--� ECORD ID A 3 ( (o <br /> DORESS 25 _ a f(i. 7z� ,f ANK ID # <br /> ANK SIZE UEL TYPE DI eSC� <br /> 11. GENERAL SITE HISTORY <br /> H <br /> Is permit current? es o ermit lFacitity Status Code 6,3L, cc.Soil/GW Cont es o <br /> umber of Tanks at facility I Ikge of Tank(if available) ype of Tank IS teel Fbrgl ngl Dual <br /> 111. TANK HISTORY <br /> as Tank tested7 as IF <br /> ailed precision test ? es o If yes, give date(s) <br /> as a repair made to the tank system? es No I IIf yes, what was repaired7 <br /> as repair done under inspection? es o ere soil samples analyzed? es o T%E PH-G PN-D b/EDB <br /> Type of failure/discharge I loatastrophic long-term Leakage I lDverfiLl I knknown I lother: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es I o epth to Ground Water of/Year verage Annual Precipitation k= 4 0-25 <br /> n-site WeLI(s) eso umber & Type Irr Cm ub <br /> S core S Score S Score <br /> Distance to WeLI(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R condition R condition R onditi on <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 25-50L <br /> Fractures in subsurface (applies to foothills or mountain areas) - None Unknown resent <br /> Average Annual Precipitation (inches) KXXMX <10 9 10-25 Kmxux 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 1 /0 + lP + C1 W <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts 41 - 48 pts 40 pts or less <br /> T X E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM 1 50 50 50 3 .3 1. 1. NA�3 <br /> ample Result: ASOL E 1000 100 10 <br /> /1.r/ W-0 A%IMUN ALLOWABLE TPH LEVELS (PPM) <br /> rl TPH IDIES L 1 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contami ion is present not complete the Leaching potential <br /> analysis. (i.e., site is currently an UGT 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 /> 13 Levels for BT%&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 Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure es o 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 F EFERRED TO SITE MITI GAT[ON FOR EVALUATION ES O <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/94 <br /> � y <br />