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SAN JOA0UIN'-eWNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEZLTH DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE 3 - <br /> AME OF FACILITY WEEPS CODE <br /> DRESS ,/& J ANK ID a <br /> ANK SIZE ��v UEL TYPE I le <br /> 11. GENERAL SITE HISTORY <br /> >t <br /> s 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) IType of Tank teem brgl ntgl I Dual <br /> III. TANK HISTORY <br /> Jas Tank tesled? es o ailed pre#No <br /> ? es o If yes, give date(s) <br /> Jas a repair made to the tank system? esf yes, what was repaired? <br /> as repair done under inspection? es soil sampLes analyzed? es o TXE PH-Gype of failure/discharge atastrophicm leakage verfilL known they: <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 /6 of/Year verage Annual Precipitation = 4 0-25 <br /> -Site WeLL(s) es o 1 r 8 Type Irr on ub <br /> S core S core S core <br /> istance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> V. R odition R conditi on R ondition <br /> Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) �LJ- 9�� •(o >100 1-100 _ 25-5011 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) xxxx 00 9 10-25 xxx 26-401 <br /> an-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 leas[ 4ore than <br /> xmx 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, N Gess <br /> _ N,.i2.3 e T X E B T X E <br /> MAXIMUM ALLOWABLE S-T-X-E LEVELS (PPM) 1 50 SO 50 .3 .3 1. 1. NA13 <br /> ample Result: SOLI NE 1000 100 10 <br /> G i9, +' AXIMl1M ALLOWABLE TPH LEVELS (PPM;) <br /> m •• (' TPH LESEL 1 10,000 1 1000 100 <br /> OOTNOTES: "`If documented soil and/or ground water contamination is present, do not complete the Leaching tential <br /> anaLysis. 0.e., site is to tly on Contamination List for soil or ground water.) <br /> L 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, scor po n s. <br /> L Levels for BTXBE are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPH Concentrations > AlLowable Levels Yes o <br /> f2. Recommend Site Closure res I �lo I �>If Yes, Refer to Site Mitigation for Evaluation <br /> V(1- 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 /> EM 23 80 (UGTWKSHT)\5/90 <br />