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SAN JOAOUI*HTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL A DIVISION <br /> )' UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> ATE /—S— <br /> AME OF FACILITY <br /> - UEFA$ CODE <br /> DDRESS I Q C ANK ID # <br /> ANK SIZE O © UEL TYPE J <br /> It. GENERAL SITE HISTOR O <br /> Is permit current? es o ermit # acil icy Status Code oc.Soil/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tank teal Fbrgl ngl Dual <br /> 111. TANK HISTORY <br /> E <br /> Mmade�to <br /> o ailed precision test v es o If yes, give date(s)the tank system? es No f eswhat epaired? <br /> r inspection) es o arc soil samles anal ted? 7b/EDB <br /> arge atas troph is longterm leakage verfill nknown cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received as o epth to Ground Water of/Year verage Annual Precipitation <br /> -Site Wells) as o umber 8 Type Irr om ub <br /> S core S core S core <br /> istance to Wells) from Tank it; ft; ft C 0 pts C pts C <br /> ' 0 'f 0 if 0 .fpts <br /> R ondition R anditi on R ondi[i on <br /> Site Feature Leaching Potential Analysis E is met E is met E 's met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1.100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) xxxxx <10 9 10.25 xxxxxx 26.40\2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) 'l O None Unknown resent <br /> Inique site features: Recharge area, coarse soil, nearby wells. (�, At least ore than <br /> xxxxx None _1 one one <br /> COLUMN TOTALS»>TOTAL POINTS O ♦ l u . S <br /> 'ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or less <br /> i'U� a l0 Yea B T X E B i X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> -a-mpIle Re ult: ASOLINE 1000 100 10 <br /> fj AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> 00 NOTES: •K n ed soil and/or ground water contamination is present, do not complete the teaching ng potential <br /> analysis. (i.eo 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 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 8 E or TPN Concentrations > Allowable Levels Yes o <br /> I2. Recommend Site Closure�'es I �(o I �If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/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)\5/90 <br /> EH 29 80 <br />