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SAN JOACUINI MTY PUBLIC HEALTH SERVICES/EYVIRORMENTAL HEALTH DIVISION <br /> I. UST WORKSHEET FOR SITE wOSURE EVA=TION ATE I <br /> AME OF FACILITY i c CORD ID -- <br /> DRESS i s v ,,4 ARK ID 4 <br /> SANK SiZEId 00-DlFukTYPE I <br /> II. GENERAL SITE HISTORY <br /> Is Permit current? es of ermit - acility Status Code oc.Sail/GW Cant es �lo <br /> Numoer of Tanks at facility I1ge of Tank(if available) Type of Tank Ft.71 rgl I �ngl Dual <br /> ill. TANK HISTORY <br /> Las Tank tested? esI 1lo IF precision test ? I es I o I f yes, give dates) <br /> :as a repair made to the tank system? es I No _F;;_ <br /> yes, what was repaired? <br /> I <br /> as repair done under inspection? les I IVP I ere soil samples analyzed?IYe: o I TXE I ITPH-G i H-0 I I b/E08 <br /> Ifype of failure/discharge i tastrophicl long-term leakageitl I they: <br /> iV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SIT'c DETAILSlCOLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samoles Received les o pepth to Ground Water I�Q ef/Year , �verage Annual Precipitation I4= Ii4 h0-z5 <br /> t <br /> -Site Well(s) IYes Aro It r & Type 1 I rr I �rm I �etb <br /> S i Score 5 Score S care <br /> �istance to WeIL(S) from Tank ( ft; ft; ft C I 0 pts C 9 pts C pts <br /> 0 - 0 f 0 f <br /> R i t i a n R condition R ondition <br /> V Site Feature - Leaching Potential Analysis,3O� !� c s met E is met E its met <br /> i <br /> Mini.a.=n Depth to grounewarer from the Sail Sample (feet) .-100 1-100 I 12-50\1 <br /> Fractures in subsurface (applies zo foothills or mountain arras) I U INone I I Unknown I resent <br /> Average Annual Precipitation (inches) =xxxx ( <10 I 9 110-25 �xxx:ooc 126-40\Z <br /> an-!lade conduits which increase vertical migration <br /> bfleaczate 0.e_ septic systems, water wells, ponds) /O ( None I Unknown ` resent <br /> lJnicue size features: Recharge area, coarse sail, or wells. At least are than <br /> i CM.•.rcipa1=.-2000 ft; domestic=>500 ft; irr/agricuLzurat=present? Hone ( I one one <br /> COLUMN TOTALA»TOTAL POINTS <br /> Sample Resutt: (8 T X OR 'c) RANGE OF TOTAL POINTS 9 pts or more I Gt - ;8 pts 40 <br /> '9 it /V D B T X 'c B T X \3 <br /> b"�`� 1(rD MAXIMUM ALLOWABLE B-T-X-c LEVELS (PPM) 1 50 ( 50 50 I .� �.3 11. 1. NA\ <br /> ample Result: LIRE 1 1000 I 100 10 <br /> �. L I 0 1141-kv%. IMUM ALLOWABLE TPH LEVELS (PPM) <br /> IESEI. 10,000 ( 1000 100 <br /> gg� TPH <br /> FOOTNOTES: —if docunented soil and/or ground water contamination is present, do not complete the lead�i <br /> analysis. (i.e., site is currently an UGT Contamination List for sail or ground water.) <br /> \1 If depth is > 5 ft. and < $ ft., score 0 points. If depth <=5 ft-, do not use table. <br /> \2 If precipitation is > GO inches, scare 0 points. <br /> Levels for STXSE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> Vt. STAFF RECOMMENDATION/CONCLUSION S 4iV►No.evy 1 i4+ b <br /> IAre BTX & c or TPH Concentrations > Allowable Levels es I o J0 <br /> 2. Recommend Site Closure es 1 o If Yes, Refer to Site Mitigation for Evaluation <br /> II. REVIEW EVALUATION - TO BE COMPLETED 8Y A SUPERVISOR/LEW SENIOR <br /> ONCJR WITH STAFF RECOMMENDATION FOR CLOSURE I(ES NO �tE=ERRED TO SITE MITIGATION FOR EVALUATION �s I �o <br /> A.. REr'cRRED i / / bATE CLOSURE LETTER MAILED <br /> i <br /> AME OF <br /> VALUATOR <br /> =H 23 80 (UGTWKSHT)\5/94 <br />