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Aea � s 1 . <br /> SAH JOAOU ;CUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL TA DIVISION <br /> [• � UST WORKSHEET FOR SITE CLOSURE EVALUATION '`� ATE q8 <br /> AME OF FACILITY ECCRD ID <br /> DDRESS <br /> ANK ID x <br /> ANK SIZE IFUEL TYPE <br /> II- GENERAL SITE HISTORY <br /> Is permit current? fes o 1 IPermit 0 - ica lity Status Codeoc,Soil/Gu Cont es a <br /> i <br /> umber of Tanks at facilityg oe f Tank(if available) �fype of Tank tee{ 1SngL Dual <br /> III. TANK HISTORY <br /> as Tank tested? es a ailed precision test 7 es o If yes, give date(s) <br /> Jas a repair made to the tank system? e5 Na 11f yes, what was., ired7 <br /> E <br /> ir done urxier inspection? es o oil samples analyzed? es a 7XE PH-G PH-D b/EDBfailure/discharge trophic long-term leakage -fill nown Cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es o I epth to Ground Water 1, of/Year C; verage Annual Precipitation k= 4 0-25 <br /> On-Site WeLL(S) es o umber 8 Type Irr om ub <br /> S core S core S core r <br /> istance to We M s) from Tank ft; ft; ft C 10 pts C pts C pts <br /> 0 f 0 if 0 f <br /> R ondition R onciition R ondition <br /> N. Site Feature - Leaching Potential Analysis E is met E is met E s met <br /> Minimum Depth to groundwater from the Sail Sample (feet) >100 I 1-100 25-50L <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> I <br /> Average Annual Precipitation (inches) _ xxxx <10 9 10-25 xxxxxx 26-402 <br /> II an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) /0 Hone Unknown Present <br /> niGue size features: Recharge area, coarse sail, or ,tells. At least ore than <br /> [Muncipal=>2000 ft; domestic=>500 ft; irr/agricultural resent] x Hone one one j <br /> In 1 <br /> COLUMN TOTALS>>>TOTAL POINTSr ( • q-3 <br /> II ✓ <br /> amllple Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. E NAS <br /> I <br /> ample Result: LINE 1000 100 10 <br /> J4AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH rIESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil ard/or ground water contamination is present, do not complete the Leaching potential s <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 c5 ft., do not use table. <br /> If precipitation is > 40 inches, score 0 points. <br /> 13 Levels for BTX8E 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 TPN Concentrations > Allowable Levels tYes o N„ ItA <br /> f�XJ v V <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / WE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/94 � <br />