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SAN JCAWIN Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE DIVISION <br /> 1. T WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY p! / �1 EEPS CODE <br /> DRESS2 Of!r _ .Y 1f ANK ID # - <br /> TANK SIZE UEL TYPE <br /> II. GENERAL SITE HISTORY <br /> ,M <br /> II's permit current] es o ermit # - acility Status Code oc.Soil/GW Cont es o <br /> ry mber of Tanks at facility ge of Tanks(if available) ype of Tank teeL Fbrgl rwgl Dual <br /> Illi. 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 I Irf yes, what was repaired] <br /> F <br /> air done under inspection] es o ere soil samples analyzed] es o T%E PH-G PN-D b/EDB <br /> failure/discharge atastrophic long-term Leakage verfitl noun 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 L 3 ; verage Annual Precipitation 4 0-25 <br /> :In-Site WeLL(s) es o umber & Type Irr aslub <br /> S Score S core S 3care <br /> istance to WeLL(s) from Tank ft; ft; ft C 10 pts C pts C 3 pts <br /> 0 if 0 if 0 if <br /> R condition R condition R ondition <br /> Site Feature - Leaching Potential Analysis E is net E is net E is met <br /> inimum Depth to groundwater from the Soil Sartple (feet).'-,_r %3 y >100 1-100 - 25-50L <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage AnnuaL Precipitation (inches) xxxx <10 9 10-25 x 26-40L <br /> an-Made conduits which increase vertical migration c <br /> f leachate (i.e., septic systems, water wells, ponds) More J Unknown resent <br /> ique site features: Recharge area, coarse soil, nearby wells. Q At Least ore than <br /> None / one one <br /> COLUMN TOTALS>>>TOTAL POINTS t L <br /> ample Result: IS T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or Less <br /> OI m 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 /> aapi. Result: OLINE 1000 100 10 <br /> IMUM ALLOWABLE TPH LEVELS (PPM) <br /> Jl I TPH j') IESEL 10,000 1000 100 <br /> FOOTNOTES: --If docuaented soil and/or ground water contmination is present, do not comp Lete the leaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or grand water.) <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> L If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppa (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPN Concentrations > Allowable Levels Yes o <br /> 2. Recomnetd Site Closure Fes Fo If Yes, Refer to Site Mitigation for Evaluation / 1/ <br /> VII. REVIEW EVALUATION - TO BE C0IPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF I <br /> VALUATOR 2`�.`l <br /> EH 23 80 (UGTWKSHT)\5/90 <br />