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SAN JOAOUI ANTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL PH DIVISION <br /> 1. UGST WORKSHEET <br /> " FOR SITE CLOSURE EVALUATION ATE <br /> qME OF FACILITY DoerktCtcl ((PLO,- &"- ciK WEEPS CODE <br /> pDRESS 1, GJ rJO SYtC1.l.� tS ANK ID # <br /> TANK 512E UEL TYPE 34- 1425-0+ - 3,o0D�g" ZeD Gv <br /> 34_ 1x29-d2- 2,D00$`R L5^LQ4F("i 64,5 <br /> 11. GENERAL SITE HISTORY :. <br /> Is permit current? es o ermi[ # acil ity S(atus Code J13iD oc.Soil/GW Cont es o <br /> umber of Tanks at facility 'a 9e of Tanks(if available) 1(14V6 ype of Tank IS <br /> teal brgl ngl Dual <br /> III. TANK HISTORY Irx5t-4� 19 t(s <br /> ✓evvov¢cl 5.21 •$ <br /> ns Tank tested? es IFailed precision test ? as o If yes, give date(s) <br /> as a repair made to the tank system? Yesi No 1 11f yes, what was repaired7 <br /> ns repair done under inspection? es o ere soil samples analyzed? as Io TXE PH-G PH-D b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfill nknown cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> soil Samples Received eso epth toGround Water 1,45 cf/Year y g(° verage Annual Precipitation = 4 10-25 <br /> n-Site Wells) as I o I umber 8 Type Irr I om I ub <br /> S core S core S Score <br /> Distance to Well(s) from Tank ft; ft; ft C 10 pts C pts C 5 pts <br /> 0 if 0 1f o if <br /> R ondition R ondition R ordi(ion <br /> V. Site Feature - Leaching Potential Analysis E is met E is met Es met <br /> inimum Depth to groundwater from the Soil Sample (feet)45,(y+ 33 >100 1.100 5 25.50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) t b None Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10.25 KXXXXXX 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., se,Etic systems, water wells, ponds) None Unknown resent <br /> lnique site features: Recharge area, coarse soil, nearby wells. At least r lore than <br /> xxxxx None C� one Jr one <br /> COLUMN TOTALS>>>TOTAL POINTS <br /> Simple Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or Less <br /> l PPt"'Y B T_T5X E 6 T X. E <br /> MAXIMUM ALLOWABLE O-T-X-E LEVELS (PPM) 1 500 50 .3 .3 1. 1. NA\3 <br /> -ample Result: ASOLINE 1000 100 10 <br /> N D9 1 OP Y✓ AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> l:• P TPH IESEL 1 70,000 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 LOT 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 BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> Of i-c,v.w- VCnti <br /> 1, Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evatuation �VL� <br /> VII, REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> .ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> n <br /> AME OF <br /> .VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />