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! SAN JOAOUIY. NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL Hf VISION <br /> I• � ,� UST WORKSHEET FOR SITE CLOSURE EVALUATIONS ATE 7__'V <br /> AME OF FACILITY (n•O CORd ID <br /> ZZ 76 <br /> DDRESS ANK ID <br /> It. GENERAL SITE HISTORY �� 1'�. • I , <br /> Is permit current? es o ermit # - acility Status Code oc.Soit/GW Cont es EEO <br /> umber of Tanks at facility �•3 ge of Tank(if available) ype of Tank teal Fbrgl ngl I Dual <br /> 111. TANK HISTORY <br /> as Tank tested7 es o ailed precision test ? es a if yes, give date(,) <br /> as a repair made to the tank system? as No f yes, what was repaired? , <br /> as repair done under inspection? es 1 40 ere soil samples analyzed? es o TXE PH-G PH-D b/EDB <br /> Type of failure/discharge atastrophic long-tern leakage verfitl known cher: <br /> 1V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Ifee o epth to Ground Water of/Yeark0co, verage Annual Precipitation k= 4. 0-25 <br /> n-Site Wells) as o umber & Type Irr om ub 1 <br /> Score S core S core ! <br /> istance;to WeIL(s) from Tank ft; _f t; ft C 0 pts C pts C 5 pts <br /> 0 if 0 if 0 if <br /> R ondition R ondition R ondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> i <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 25-50L <br /> Fractures in subsurface (applies to foothills or mountain areas) More ? Unknown resent <br /> k <br /> verage AnnuaL Precipitation (inches) xxxx <10 9 10-25 xxxxxx 26-40�_2 z <br /> Ian-Made conduits which increase vertical migration q <br /> f leachate (i.e., septic systema, water wells, ponds) None I Unknown resent <br /> pique site features: Recharge area, coarse soil, or wells. At least ore than <br /> (MuncipaL=,2000 ft; domestic=>500 ft; irr/agricultural=present) xxx None 29 one one <br /> COLUMN TOTALS»>TOTAL POINTS ' <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> B T X E B T X E , <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. MA13 <br /> Sample ResulC: ASOLINE 1000 100 10 <br /> ' AXIMUM ALLOWABLE TPN. LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the leaching potential � <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> \1 If depth is > 5 ft. and < 25 ft., store 0 points. If depth c5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are:•BTX & E or TPH Concentrations > Allowable Levels Yes o ' <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> V11. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 I EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED / / <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/94 <br /> i <br />