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SAN JOAOUIA**NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL ^H DIVISION <br /> I. UST WORKSHEET FOR SITE CLOSURE EVALUATION ; ATE S I , <br /> AME OF FACILITY ECORD ID <br /> DDRESS lhn5 LANK <br /> TANK SIZE UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> is permit current? es o ermit lFaciLity Status Code oc-So <br /> iL/GW Cont es o <br /> umber of Tanks at facility ge of Tank0 f available) ype of Tank teel Fbrgi ngl Dual <br /> III. TANK HISTORY <br /> as Tank tested? es o ailed precision test 7 es a If yes, give date(s) <br /> Jas a repair made to the tank system? es No 1 11f yes, what was repaired? <br /> as repair done under inspection? es a ere sail samples analyzed? es o TXE PH-G PH-0 b/EDB <br /> ype of failure/discharge atastrophic long-term leakage I loverfiLI Hawn I lother: <br /> 1V- REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> ail Samples Received es o epth to Ground Water a O of/Year .R �(}$3 verage Annual Precipitation = 4 0-25 <br /> n-Site Wells) es o umber & Type It om ub <br /> S Score 5 Score 5 core <br /> istance to Wells) from Tank I .ir-—0f t; ft; ft C 10 pts C 9 pts C pts <br /> 0 if o if 0 f <br /> R condition R condition, R Pondition <br /> Site Feature - Leaching Potential Analysis E is met E is met E s met <br /> inimum Depth to groundwater from the Sail Sample (feet) V+ >100 1-100 Q 25-501 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown 3resent <br /> Average Annual Precipitation (inches) KXXXXX 410 4 10-25 xxxxxxx 26-40_\2 <br /> an-Made conduits which increase vertical migration <br /> of Leachate (i.e., septic systems, water wells, ponds) None 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=presentl x None 9 one one <br /> COLUMN TOTALS—TOTAL POINTS 3 0 -36 <br /> aBmp[e,,&esu(y,g T X OR E) RANGE OF TOTAL.HES <br /> 4 pts or more 41 - 48 pts 40 pts or less <br /> ���� '•�P � B T Ix E 8 IT X E <br /> x_. 1.5i�}t-•again <br /> ,y ppM^. Is,�� MAXIMUM ALLOWA8LE 9-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. HAL <br /> Sample Result: SOLINE 1000 100 10 <br /> IMUH ALLOWABLE TPH LEVELS (PPM) <br /> qtbt)spin TPH(a) 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 /> L if depth is > 5 ft. and < 25 ft., score 0 points. If depth -5 ft., do not use table. <br /> L If precipitation is > 40 inches, score 0 points. <br /> 3 Levels for BTX&E are not applicable at a TPH concentration of 10 Mn (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 a If Yes, Refer to site Mitigation for Evaluation <br /> VI1. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES- - 0 ' EFERRED TO SITE MITIGATION FOR EVALUATION fES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/44 <br />