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Viso �y <br /> SAN J0AaIIN CCU.' USLIC HEALTH SERVICES/ENVIRONMEHTAL HEALTT •iSION <br /> I. UC-..,eWORKSHEET FOR SITE CLOSURE EVALUATICN AE <br /> AME OF FACILITY J US 0 �1 50-yl 62z � EPS COOS <br /> AORESS 2f S C&t, rer2 rANK ID X - <br /> TANK SIZE a UEL TYPE D J <br /> II. GENERAL SIT HISTORY <br /> Is permit current? es a ermit 0 - aciticy Status Code oc.Sail/Gw Cont es a <br /> umber of Tanks at facility ge of Tanks0 f available) 1 ype of Tank teel !?rg[ mgt Oua! <br /> 111. TANK HISTCRY <br /> Jas Tank tested? esI\ro ailed precision test ? es o I[fl yes, give date(s) S�/f�r; <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> ,as repair done under inspection? es o ere snit samples arta[yzed2i es o TX$ PH-G PH-0 b/EDB <br /> . ype of failure/discharge atastrophic long-term leakage verfitt known cher: <br />:V. -REMOVAL HISTORY (ATTACH tHSPECTICH REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> wit Samples Received es a epth to Ground tracer of/Year ; verage Annual Precipitation <br /> -Site WeEI(s) es o umber & Type Irr tae ub <br /> S Score S Score S core <br /> )!stance to WeE[(s) from Tank ft; ft; ft C 10 pts C 2 Pts CP is <br /> 0 it 0 if O f <br /> R onditian R ondition R cordition <br /> 61. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the sail Sanple (feet) >100 t-100 Z5-50�1 <br /> ractures in subsurface (applies to foothills or mountain areas) None 17 Unknown resent <br /> verage Annual Precipitation (inches) Cxxxxx <10 9 10-25 xxxxxxx 25.4012 <br /> I <br /> an-Made conduits which increase vertical migration <br /> Df leachate (i.e., septic systems, water wells, ponds) None unknown resent <br /> ique site features: Recharge area, coarse soil, nearby wells. At least ore than <br /> one <br /> xxxx None one <br /> I <br /> COLUMN TOTALS>>>TOTAL POINTS <br /> ample Result: (B TX OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> 8T ! Ix E B T X E <br /> MAXIML24 ALLOWABLE B-T-X-E LEVELS (PPM) 1 501 50 150 .3 .3 1. 1. 1 NA\3 <br /> amp/�le Result: ASOLINE 11000 10o 10 <br /> a 90 ��OTPH AxIMLrH ALLOWABLE TPH LEVELS (PPM) �IESEL 10 000 1000 100 <br /> FOOTNOTES- *'*If documented soil and/or ground water contamination is present, do not complete the teaching potentia[ <br /> analysis. (I.e-, site is currently on UGT Contaminacnon List for soil or ground water.) <br /> k1 If depth is > 5 ft. and < 25 ft., scare 0 points. If depth <=5 ft., do not use ratite. <br /> N2 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 /> STAFF RECCMMEMDATION/CCKCLUSION If <br /> ALIowa <br /> Levels �Yes o1. Are BTX rIA F� <br /> 2. Recomnerad Site Ctosure es o If Yes, Refer to Site Mitigation for Evaluation <br /> I. REVIEW EVALUATION - TO 3E CCMPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE JMITIGATICN FOR EVALUATION ES 100 1 ; <br /> ATE REFERRED / / Cf ATE CLOSURE LETTER MAILED <br /> in►+E OF <br /> ;VALUATOR <br /> S <br /> CH 23 do (UGTuKSHT)\5/90 <br />