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SAN JOAOUIR#NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL KOH DIVISION1. 7�� �± <br /> UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE `� <br /> AME OF FACILITY T ECORD ID , 3 3 <br /> DDRESS �1� 1 ANK ID # -RJ 5 <br /> ANK SIZE UEL TYPE <br /> Il. GENERAL SI E HISTORY <br /> 3 .a acility Status Code cc.Soil/GW Cont es o <br /> Is permit current? as o ermit # c�� <br /> umber of Tanks at facility ge of Tank(if available) 90 ype of Tank reel Fbrgl ngl Dual <br /> III. TANK HISTORY <br /> as Tank tested? es o ailed precision test ? es o If yes, give date(s) <br /> as a repair made to the tank system? es No f yes, what Was repaired7 <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 nknoun then: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es o epth to Ground Water of/Year , <br /> verage Annual Precipitation = 4 0-25 <br /> n-Site Wells) es o umber & Type Irr om ub S core S core S Score <br /> istance to Well(s) from Tank ft; ft: ft C 0 pts C pts C 5 Pts <br /> 0 -f 0 if 0 if <br /> R ondition R ondition R condition <br /> Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) <br /> )100 1-100 © 25-50L <br /> ractures in subsurface (applies to foothills or mountain areas) <br /> None Unknown resent <br /> verage Annual Precipitation (inches) KXXMX <10 9 10-25 xxxxxx 26-40L <br /> an-Made conduits which increase vertical migration 1� Nie Unknown resent <br /> I leachate (i.e., septic systems, water wells, ponds) / <br /> At least ore than <br /> pique site features: Recharge area, coarse soil, or cells. one one <br /> (Muncipa L=>2000 ft; domestic=>500 ft; irr/agricultural=present) �^lxxxx None <br /> COLUMN TOTALS»>TOTAL POINTS A O + D <br /> ample Result: (S T ORE) 0 ✓VL RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> S LJ C3='��PP B T % E B T X E <br /> Yew MAXIMUM ALLOLIABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 7. 7 NA <br /> 10 <br /> ample ResuLt: <br /> 7a,f p p y.� fPN GAXIMUM ALLOWABLE TPH LEVELS (PPM) ASOLINE 1000 100 IESEL 10,000 1000 <br /> 11 100 <br /> TPH Q <br /> OOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the leachi ial <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 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 Concentrations > Allowable Levels Yes o Is SAvKpk E�St' X v00001 <br /> uSy qrpn� o s <br /> 2. Recommend Site Closure es o Lf Yes, Refer to Site Mitigation for Evaluation 7 ,> LI#X /1L+ 42, 0 `l <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LE SENIOR e$ -2 PLO M �J <br /> ONCUR WITH STAFF RECOMMENDATION FOR LOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED Ol / / hTE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/94 - oyi �� P ) ,,.� <br />