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SAN JOADUIHJNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL *H DIVISION <br /> UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY (' 7 ECORD ID -3 3 <br /> ADDRESS a$ ANK ID # 3 <br /> TANK SIZE <S�J UEL TYPE liL,:.. C „c„C <br /> 11. GENERAL SITE HISTORY L- u-�C )/ .t <br /> rfer <br /> s o ermit # - acility Status Code oc.Soil/GW Contes oof Tanks at facility 41 ge of Tank(if available) ype of Tank teal Fbrgl ngl Dual <br /> III. TANK HISTORY <br /> as Tank tested?I <br /> ailed precision test 7 es o If yes, give date(s) <br /> as a repair madk system? es No f yes, what was repairedl <br /> Jas repair done ti on7 es o ere soil samples analyzed? es o TXE PH-Gype of failure/ atastrophic long-term leakage verfill nknown ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es o epth to Ground Water of/Year veraTPrecipitation Annualtion = 4 0-25 <br /> n-Site Well(s) es o umber 8 Type Irr pm ub S core core <br /> istance to WeLI(s) from Tank ft: ft; ft C 0 pts pts <br /> 0 if -f <br /> R onditim ondition <br /> i. Site Feature - Leaching Potential Analysis E is met is met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 25-SOL <br /> Fractures in subsurface (applies to foothills or mountain areas) i (� None Unknown resent <br /> Average Annual Precipitation (inches) xxxxx <10 9 10-25 KXXXmx 26-40L <br /> Ian-Made conduits which increase vertical migration //`` None Unknown resent <br /> f leachate (i.e., septic systema, water wells, ponds) ' V <br /> pique site features: Recharge area, coarse soil, or wells. At least 4ore than <br /> (Muncipal=>2000 ft; domestic=>500 ft; irr/agricultural=present] KXxmx None one one <br /> N;4- COLUMN TOTALS»>TOTAL POINTS <br /> �C) + ✓� <br /> gff <br /> T % OR E) O m RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> Q . B T X E B T E.)jo MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 -3 .3 1. 1 NA�3 <br /> ASOLINE 1000 100 10 <br /> jTPH If AXIMUN ALLOWABLE TPN LEVELS (PPM) IESEL 10,000 1000 100 <br /> FOOTNOTES: --*If documented soil and ground water contamination is present, do not complete the leechnng n is[ <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 TPN concentration of10 ppm (gasoline) or 1000 ppm (diesel). o <br /> VI. STAFF RECOMMENDATION/CONCLUSION f/T��I -/f ,'ys-w�-�•� ✓`-�"�U"�"���nry'�1 ✓y{j,�1 j�,[�y� <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure 1Yes o If Yes, Refer to Site Mitigation for Evaluation L/ ' <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVI SO LEAD SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE E 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED �" / 1, / '� ATE CLOSURE LETTER MAILED <br /> AME OF , <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/94 <br />