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SAN JOAOUI*NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H.H DIVISION / <br /> I. UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE 7—b y r <br /> AME OF FACILITY ECORD to �3 J <br /> DDRESS a$ ANK ID # 2 5 2 <br /> 7, <br /> TANK SIZE , (),()00 UEL TYPE C: u <br /> If. GENERAL SITE HISTORY <br /> Is permit curo ermit # - acility Status Code - oc.Soil/GW Cont es <br /> rent? es o <br /> umber of Tanks at facility ] ge of Tank(if available) IT <br /> ype of Tank tee( Fbrgl ngl Dual <br /> 111. TANK HISTORY <br /> as Tank tested? es Vo ailed precision test 7 es o If yes, give date(s) <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> Jas repair done under inspection? es qo ere soil samples analyzed?IYes X o I TXE PH-G I PH-D b/EDB <br /> Type of failure/discharge atastrophic long-term leakage I IDverfitl nknown 1 10 <br /> cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es 1,'4- 1 epth to Ground Water i 0 of/Year F& verage Annual Precipitation = 4 0-25 <br /> n-Site WeIL(s) es o umber & Type Irr am ub <br /> S 3core S core S 3core <br /> )!stance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R odition R condition R ordition <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 /> verage Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40J2 <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 lore 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 19 pts or more 41 - 48 pts 40 pts or less <br /> 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. NA_\3 <br /> ample Result: ASOLINE 1000 100 10 <br /> K �' AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> 10 TPH-0 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the leaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or grovel 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 /> \33 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOFMIENDATION/CONCLUSION .S Qi'f'✓�^^" <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes o // (�4, <br /> GfiY!CEGC ); <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation 1 <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/L AD SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/94 <br />