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SAN ZOACUIN COUi�t1HLIC HEALTH SERVICES/ENVIRCNMENTAL HEALT' •ISION <br /> I UG.ce-WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> C /•� EPS CME /OClo <br /> A!t OF FACILITY J USI/ !5a"N �l <br /> ODRESS 2'f S . LF.f`Ne4 AHK 1D <br /> rANK SLZE D UEL TYPE D <br /> 11. GENERAL SITd HISTORY <br /> Is permit current? es a ermit pE911f <br /> - aeility Status Code oe.Soit/Gu Cant es o <br /> ur�ber of Tanks at facility ID Tanks(if available) �� glType of Tank 13teet MFbrgt nql Dual 15 <br /> III. TANK HISTORY <br /> as Tank tested? es a ailed precision test 7 es o iff yes, give dates) Z/ <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> Was repair done under inspeetion7 es No ere soi( samples analyzedZes o TXE PH-G PH-D b/EDB <br /> ype of failure/discharge atastraphic long-term leakage verfil( own 10cher: <br /> LV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA F�R LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es a epth to Ground Water of/Year ; verage Annual Precipitation <br /> -Site ueLL(s) es o umber Type irr tm E <br /> S core S care S core <br /> istance to Wells) from Tank ft; ft; ft C ia pts G 7 pts C pts <br /> 0 if 0 if 0 f <br /> R ondition R condition R ardition <br /> 01. Site Feature - Leaching Potential Analysis E is met E is met E s met <br /> inimum Depth to groundwater from the Soil Saapte ?feet) I >I00 I-100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> vcrage Annual Precipitation (inches) x)Rx <10 9 i0-25 xxxxxxx 26-40\2 <br /> an-Race 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. I At Least ore than <br /> xxxx None _I one one <br /> COLUMN TOTALS>>>TOTAL POINTS <br /> ample Result: (a T.X OR E) RANGE OF TOTAL POINTS 9 PCs or more 41 - 48 pts 49 pts or Less <br /> a T x I E a T 1 x E <br /> MAXIMLM ALLOWABLE 9-T-X-E LEVELS (PPM) I 50 50 50 .3 .3 1. 1. NA\3 <br /> ampLe Resu <br /> rlt <br /> l: hASOLIHE 11000 I00 10 <br /> jqD `7yTPt! LAXIMUM ALLOWABLE TPN LEVELS (PPM) LE SEL 10,000 1000 100 <br /> FOOTNOTES: -'-If documented soil and/or ground water contamination isfpresent, do not complete the leaching potential <br /> analysis. (f.*., site Is currently on UCT 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. f <br /> \3 Levels for 8TX&E are not applicable at a TPH concentratiIan of 10 ppm (gasoline) or 100 Ppm (diesel). <br /> it. STAFF RECCWENDATION/CONCLUSION <br /> 1. Are 8TX & E or TPH Concentrations > AL(owab Levels Yes a <br /> i <br /> 2. Recommend Site Closure eso If Yes, Refer to Site Mitigatiion for Evaluation <br />':II. REVIEW EVALUATION - TO BE CCMPL=TED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES O EFERRED To SlijE 41TIGATICN FOR EVALUATIONS O <br /> E <br /> ATE REFERRED �/r ! / ' ATE CLOSURE LETTER MAILED y / <br /> i <br /> MME OF <br /> :VALUATOR <br /> CH 23 aO (UGT%jKSHT)\5/90 <br />