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SAN JOAOUIl L:CUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H: .LTH DIVISION ATE C{ X5_ �( t- <br /> I. GST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> AME OF FACILITY ,.` WEEPS CODE <br /> DRESS S ,S (/J ANK ID # <br /> TANK SIZE Dd OO UEL TYPE <br /> I1. GENERAL SITE HISTORY <br /> xx <br /> Is permit current? es o ermit # - acility Status Code oc.Soil/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) Irype of Tank teal Fbrgl ngl Dual <br /> 111. TANK HISTORY <br /> Jas Tank tested? as o ailed precision test 7 es o Lf yes, give date(s) <br /> Jas a repair made to the tank system? as No f yes, what was repaired? <br /> as repair done under inspection? as No ere soil samples analyzed? as o TXE ITPH-G 1 1, <br /> PH-D b/EDB <br /> Type of failure/discharge a[astroph is Long-term Leakage verf ill nknown then: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es o epth to Ground Water l.�S of/Year Y6 ; verage Annual Precipitation = 4 0-25 <br /> -Site Wallis) es o umber 8 Type Irr om ub <br /> S core S Score S 3core <br /> istance to WeLI(s) from Tank ft; ft; ft C 0 pts C 9 pts C 5 PIS <br /> 0 if 0 if 0 if <br /> R ondition R condition R ondition <br /> J. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> ini mum Depth to groundwater from the Soil Sample (feet) t{S_ (3 >100 1-700 S 25-SOL <br /> Fractures in subsurface (applies to foothills or mountain areas) / v None Unknown resent <br /> verage Annual Precipitation (inches) xxxx <10 9 10-25 xxxxxx 26-4012 <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, nearby wells. At least 4ore than <br /> /xxxxx None 9 one one <br /> o <br /> COLUMN TOTALS>»TOTAL POINTS <br /> angle Res,sult: ( E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> OS(; B T X E 8 T X E <br /> �a� aµ5 MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA•L3 <br /> le 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 UGT 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 /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are SIX 8 E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure IYes <br /> I o If Yes, Refer to Site Mitigation for Evaluation <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 / / /7 ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />