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SAN JOAOUINGNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL No DIVISION <br /> I, UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE 7— — y r <br /> AME OF FACILITY p 7 ECORD ID �.� 3 <br /> DDRESS a S ANK ID # 5 y,f'. <br /> Lt- <br /> TANK SIZE /6.660 IFUEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> re <br /> Is permit current? es o ermit # - acility Status Code c)'l. oc.Soil/GW Cont es o <br /> umber of Tanks at facility ge of Tank(if available) IVA1,4ZIType of Tank Leel Fbrgl ngl Dual <br /> III. TANK HISTORY <br /> as Tank tested? es o ailed precision test 7 es o � If yes, give date(s) <br /> as a repair made to the tank system? es No 1XII f yes, what was repaired? <br /> as repair done under inspection?T <br /> es 40 ere soil samples analyzed? 1Yes I o I TXE I PH-G I PH-D I b/EDB <br /> Type of failure/discharge atastrophic long-term leakage I verfill I knknown ther: <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 verage Annual Precipitation N= 4 11 <br /> 0-25 <br /> -Site Well(s) IYes o umber 8 Type Irr am ub <br /> S Score S core S Score <br /> istance to WeIL(s) from Tank ft; ft; ft C 10 pts C pts C 5 pts <br /> 0 if 0 if 0 if <br /> R ondition R ondition 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 25-50L <br /> ractures in subsurface (applies to foothills or mountain areas) ) None Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 xxxxmx 26-4012 <br /> an-Made conduits which increase vertical migration .� <br /> f leachate (i.e., septic systems, water wells, ponds) a None Unknown resent <br /> pique site features: Recharge area, coarse soil, or wells. At least ore than <br /> IMuncipal=>2000 ft; domestic=>500 ft; irr/agricultural=present) xxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS <br /> ample Result: (B T`1X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts pts or l <br /> .4 'v V B T X E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NAL <br /> ample Result: ASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> FOOTNOTES: ."•If documented soil and/or ground water contamination is present, do not complete the leeching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground-wete[,) <br /> 11 If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. \ <br /> 12 If precipitation is > 40 inches, score 0 points. <br /> 13 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel).` <br /> VI. STAFF RECOMMENDATION/CONCLUSION ,..�15 P�-�,.�,-��)',,— S h,,C�-LA�`T'�' <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o P <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigat'on for Evaluation 1 �1J <br /> i <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/ EAD SENIOR �— <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES0 EFERRED TO SITE MITIGATION FO ATION ES <br /> ATE REFERRED ' / / ATE CLOSURE LETTER MAILED <br /> AME OF �\ <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/94+1 <br />