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SAN JOAOUI I0NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL 0DIVISION <br /> I• UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY ECORD ID <br /> DDRESS ANK ID # - <br /> TANK SIZE UEL TYPE <br /> II. GENERAL SITE HISTORY <br /> Is permit current? es ' ermit # - ont acility Status Code oc.Soil/GW Ces o <br /> Ember of Tanks at facility ge of Tank(if available) ype of Tank teel Fbrgl ngl Dual <br /> Ill. TANK HISTORY <br /> as Tank tested? es IF <br /> ailed precision test es o If yes, give date(s) <br /> as a repair made to the tank system? Yes No f yes, what was repaired? <br /> as repair done under inspection? es 4o ere soil samples analyzed? es o TXE PH-G PH-D 7b/EDB <br /> ype of failure/discharge atastrophic long-term Leakage I laverfiLL I nknown I lather: <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 I izef/Yeari verage Annual Precipitation k= 4 0-25 <br /> n-Site WeLL(s) es o umber & Type Irr om I ub <br /> S Score S Score S core <br /> istance to WeLL(s) from Tank ft; ft; ft C 10 pts C 9 pts CI pts <br /> 0 if 0 if 0 'f <br /> R ondition R condition R ondi ti on <br /> Site Feature - Leaching Potential Am Lysis E is met E is met E 's met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 25-501 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) xxxx <10 9 10-25 xxxxxx 26-40L <br /> an-Made conduits which increase vertical migration <br /> f Ieachate (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 9 pts or more 41 - 48 pts 40 pts or less <br /> B T % E B T % E <br /> MAXIMUM ALLOWABLE B-T-%-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA1 <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 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 BTX&E are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure lyes I �0 I I~If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD 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 />