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SAN JOADUf . �'NTY PUBLIC HEALTH SERVICES/ENVIRONMCNTAL H: 1'H DIVISION <br /> I' GST WORKSHEET FOR SITE CLOSURE EVALUATION `` ATE 3 ! 3 <br /> AME OF FACILITY G J/J11� r I f1SWEEPS CODE <br /> DDRESS �p Ile <br /> z5AZ;9 11 ANK 1D At <br /> TANK SIZE D�D "'EL TYPE <br /> 11. GENERAL SITE HIST <br /> Is permit current? eso ermit # acility Status Code oC.Soil/GW Cont es Jo <br /> ,�. <br /> umber of Tanks at facility ge of Tanks(if available) ff ype of Tank teel Fbrgl ngl Dual <br /> II[. TANK HISTORY <br /> as Tank tested? es a ailed precision test ? es o If yes, give date <br /> as a repair made to the tank system? 1Yes No f yes, what was repairedl <br /> as repair done under inspection? es o ere soil samples analyzed? 'es Jo TXE PH-G PH-D b/EDB <br /> ;I. <br /> ype of faiture/discharge atastrophic tong-term teakage verfill nknow' Cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR'�EACHItJG POTENTIAL ANALYSIS) k <br /> d <br /> oil Samples Received es I X o I epth to Ground Water �Q� eflYear �1 �� verage Annual Precipitation = 4 10 25 <br /> -Site Wett(s) es o umber & Type Irr cm <br /> S core 5 score 5 core <br /> !stance to Wett(s) from Tank ft; ft; ft C 10 pts C 9 pts C pts <br /> 0 if 0 if 0 f <br /> R onditian R condition R ondition <br /> V. Site Feature - Leaching Potential Analysis E is mete E is met E s met <br /> inimum Depth to groundwater from the Soil Sample (feet) >I09 j 1-100 3r' 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown resent } <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10.25 xxxxxxx 25-40\2 <br /> i <br /> } <br /> in-Made conduits which increase vertical migration <br /> t f leachate {i.e., septic systems, water wells, ponds} None Unknown 2resent <br /> inique site features: Recharge area, coarse soil, nearby wells. At least 11ore than <br /> xxxx None one one <br /> F <br /> COLUMN TOTALS»>TOTAL POINTS + <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more!} 41 - 48 pts 40 pts or Less ` <br /> B T X E 1 B X E <br /> MAXIMUM ALOWABLE B-T-X-E LEVELS (PPM) I 50 50 Sol .3 J.T <br /> 3 1. 1. NA\3 <br /> Sample Result: ASoONE101)0 } 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) '1. <br /> TPH IESEL 10,000 1000 100 <br /> OOTNOTE$: ***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. i <br /> \2 If precipitation is > 40 inches, score 0 points. I ; <br /> \3 Levels for BTX&E are not applicable at a TPH concentration of i0 ppm (gasoline) or 100 ppm (diesel). i <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1, Are BTX & E or TPH Concentrations > Allowable Levels Yes <br /> 2. Recommend Site Closure IYes I o If Yes, Refer to Site Mitigation for Evaluation <br /> 1 <br /> M. REVIEW EVALUATION - TO BE COMPLETED BY SUPERVISOR/SENIOR J <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES '0 EFERRED TO SITE hkITIGATION FOR EVALUATION ES O <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> � L i <br /> AME OF y <br /> _VALUATOR � <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 �' <br />