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AL <br /> SAN J =L�OUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTC� TH DIVISION <br /> J� UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> E OF FACILITY +- () (.n 5 ATE 8 <br /> �J C � � �0 l_ 7 <br /> DRESS66 /� WEEPS CODE (O <br /> ARK SIZE D O UEL TYPE TANK'10 # -10�/_ Q <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? es o ermit # - ecility Status Code �e:* <br /> oc.So't/GW Conts o <br /> umber of Tanks at facility ge of Tanks(if available) <br /> ype of Tank teel Fbrgl ngl peal <br /> IJI. TANK HISTORY <br /> as Tank tested? Pas 1 o ailed precision test ? es <br /> o [f yes, give date(s) //_�' /� !74-� <br /> as a repair made to the tank system? es No f yes, what was repaired? /t <br /> as repair done under inspection? as o <br /> ere soil samples analyzed? es o TXE PH-G PN-D b/EDB <br /> ype of failure/discharge atastrophic long-tens leakage verfill <br /> mown they: <br /> IV. REMOVAL HISTORY (ATTACH 1NSPE TION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received as o epth to Ground Water of/Year - <br /> verage Arcual Precipitation = 4 0-25 <br /> Site Well(S) as o umber & Type Irr am ub <br /> istance to Wells) from Tank ftpft, S core S core S core <br /> ft U 0 pis C p <br /> pts C is <br /> ' <br /> 0 if 0 f <br /> Site Feature - Leaching Potential Analysis R ondition R ondition R ondition <br /> . E is met E is met E s met <br /> inimum Depth to groundwater from the Soil Sample (feet)_ <br /> >100 1-100 25-50, 1 <br /> ractures in subsurface (applies to foothills or mountain areas) <br /> None Unknown resent <br /> verage Arcual Precipitation (inches) <br /> xxxxx <10 9 10-25 xxxxxx 26-40L <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) <br /> None Unknown resent <br /> ique site features: Recharge area, coarse soil, nearby wells. <br /> At least ore than <br /> xxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS + 2/- + <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more \J 1441 - 48 pts 40 pts or less <br /> TBI�i tt�l� . oa 7 <br /> 8 T X JE 8 T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 11 50 50 50 .3 .3 1. 1. NAL3 <br /> ample Result: <br /> TPH ?MUM ALLOWABLE TPH LEVELS (PPM) SOLINE 1000 100 10 <br /> IESEL10,000 1000 100 <br /> OOTNOTES: ***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 /> L If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> J2 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 es o If Yes, Refer to Site Mitigation for Evaluation <br /> VI1. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE fES 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)\5/90 <br />