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SAN JOACUIITY PUBLIC HEALTH S'cRVICES/ENVIRONMENTAL HE,_ JDIVISION <br /> !. UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> NAME OF FACILITYI ECORD ID l <br /> ADORES <br /> SI / <br /> SANK SIZE L TY14 <br /> II. GENERAL SITE HISTORY <br /> Is permit current? esc o hepAermit - acility Status Code Q a oc.Soil/GW Cont es o <br /> cancer of Tanks at facility1. /3 pge of Tank(if available) Type of Tank Isteel Fbrgt rgl Dual <br /> ill. TANK HISTORY <br /> Mas Tank tested7 es o ailed precision test ? fes o If yes, give date(s) <br /> fas a repair made to the tank system? es I No Icf yes, what was repaired? <br /> ilas repair done under inspection? est To Tere soil samples analyzed? es I �c TXE I �PH-G I PH-D b/EDB <br /> ype of failure/discharge ( tastrophicl Long-term Leakage verfill n) ther: <br /> !V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> i <br /> Soi, Samples ReceivedF o epth to Ground Water of/Year Average Annual Precipitation = 4 h0-Z5 <br /> i I <br /> Pn-Site Well(s) iYes �lo dumber & Type Irr Poml ub <br /> S core S core 5 care <br /> pis:ance to Well(s) from Tankl ft; ft; ft C 10 pts C pts C pts <br /> 0 if 0 if 0 f <br /> R ondition R ondition R andition <br /> h:. Site Feature - Leaching Potential Analysis 'e is met E is met E rs met <br /> Mini== Depth to groundwater from the Soil Sample (feet)jQ_�C�.- I >100 � �1-100 ( 25-50\1 <br /> Trac:ores in subsurface (applies to foothills or mountain areas) I None I Unknown I resent <br /> Average Annual Precipitation (inches) K=xxxI <10 , 9 110-25 x 26-40\2 <br /> __T <br /> ban-Made conduits which increase vertical migration <br /> f Leachate 0.e-, septic systems, water wells, ponds) /01 ane Unkno�n resent <br /> Jnicue site features: Recharge area, coarse soil, or welts. At Least ore than <br /> r <br /> [M cipal=>2000 ft; domestic=>500 ft; irr/agricultural=present? ( None <7 I one one <br /> COLUMN TOTALS»>TOTAL POINTS a-b + i j I + I U 3 <br /> Samote Result: (B T X OR E) RANGE OF TOTAL POINTS9 pts or more I 41 - 4$ pts 40 pts or Less <br /> All NO <br /> 8 E s M9 K MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1B 50 50 1510 <br /> ! .3 .3 1. gLea=chi <br /> amole Result: SOLINE 1000 100 <br /> — 'Cr. 1 b p�i+n IMUM ALLOWABLE TPH LEVELS (PPM) <br /> B10912Ol.TPH IESEL 10,000 I 1000 <br /> OOTNOTES: *� If documented soil and/or ground water contamination is present, do not completeanalysis. (i.e., site is currently on UGT Contamination List for soil or g11 If depth is > 5 ft. and < 25 tt., score 0 points. If depth <=5 ft., do not use tae. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for STX8E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> Vi. STAFF RECOMMENDATION/CONCLUSION �M �IS af'1 of a <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels es o <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evatuation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE �ES O EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 I <br /> ATE REFERRED I / / BATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EN 23 80 (UGTWKSHT)\5/94 <br />