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SAN JOAUIp QTY PUBLIC HEALTH SERVIC'cS/ENVIRONMENTAL ?A't ii DIVISION _ J <br /> t. UST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> {� CORD ID ATE <br /> �G 1 ANK <br /> $te a o rfPE I D <br /> it. Gomm. SITS <br /> $ Pend t CttrlerK? email - acility Status Code p oc.Soil/GW CantIrees o <br /> of Tardus at faeitity Age of Tank(if available) type of Tank teel XlFbrgt ngt I Dual <br /> tit. TANK gf=btY <br /> ADS Tank VnZedT- es ailed precision test ? fes Iyo If yes, give date(s) <br /> An a repair made,tp the tank System? es No f yes, what was repaired7 <br /> Jas repair done under inspection? �es �10 dere soil samples analyzed? es �oI TXE I PH-G PH-0 b/EDB <br /> ype of fafttae/diatbarge tastrophic I long-sena leakage verfill I they: <br /> IV. REMO1rAL NiSTMT CATTACU INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> it Samples Received es a epth to Ground Water of/Year Average Annual Precipitation <br /> -Site ueMs) ea o r & Type Fir Pon pub <br /> S Score S I Score S care <br /> istance to Vett(s) from Tank ft; ft; ft C 10 pts C 9 pts C pts <br /> 0 if 0 if 0 f <br /> R ondition R condition R ondition <br /> Site Feature —Leaching Potential Analysis E is met E is met c" rs met <br /> inim m Depth to groundwater from the Soil Sample (feet) >100 f �1-100 I 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown I present <br /> verage Annual Precipitation (inches) xxxxxx ( <10 9 110-2.5 xxxxxx 26-4012 <br /> -Made conduits which increase vertical migration <br /> 1f leachate Ci.*., septic systems, water wells, ponds) None I Unknown resent <br /> 1,5 <br /> 1. iqua site features: Recharge area, coarse soil, or wells. At least are than <br /> k (Huncipal-2000,ft; domestic=>500 ft; irr/agricut tural=present] =XXXX <br /> None I onel one <br /> 4 _ COLUMN TOTALS> >TOTAL POINTS l O + I / I + � 33 <br /> Y ample Result: (8 T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts D pts or less <br /> " KgArO /0 w �,b YD B 1 T X E 8 kT X E <br /> MAXIMUM ALLOWABLE 8-T-X-E LEVELS (PPM) 1 50 50 50 .3 I <br /> 1. 1. NA13 <br /> ample Result* LINE 1000 100 10 <br /> TPP D = 7/d00 IMUM ALLOWABLE TPH LEVELS (PPM) <br /> IESEL 10,000 1000 100 <br /> kOOTNOTES: '''"If documented soil and/or ground water contamination is present, do not complete the tea a <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> 11 If depth is > 5 ft. and < 25 ft., score 0 points. if depth <=5 ft., do not use table. <br /> 12 If precipitation is > 40 inches, score 0 points. <br /> 13 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> Vi. STAFF RECOMMENDATION/CONCLUSION 7-aioP4Z # 4z ♦ �JjJ��jr CCf� <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes o �C�L�✓�'� .S <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> VI 1. REVIEW EVALUATICN - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED I / / PATE CLOSURE LETTER MAILS <br /> AME OF <br /> VALUATOR I <br /> E4 23 80 (UGTWKSHT)\5/94 <br />