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SAN UOA*CCUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAOLTH DIVISION - <br /> I• <br /> LOST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> AME OF FACILITY 5 — C.,-_1 WEEPS CODE D0_5 <br /> DRESS I 61 W -�_J 0rj_C_A. ANK ID # <br /> TANK SIZE UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? ks o ermit # lFacitity Status Code oc.Soil/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tank tee[ Fbrgl ngl Dual <br /> III. TANK HISTORY <br /> as Tank tested? es o ailed precision test ? as o If yes, give date(s) <br /> as a repair made to the tank system? as No f yes, what was repaired? <br /> as repair done under inspection? as 0 ere soil samples analyzed? as o TXE PH-G PH-D b/EDB <br /> Type of failure/discharge atastrophic long-term leakage verfill nknown ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received as o epth to Ground Waterof/Year 1'r6b; verage Amual Precipitation = 4 0-25 <br /> n-Site Wells) as o umber 8 Type Irr mm <br /> ub lh� <br /> S core S Score S 3core <br /> istance to WeIL(s) from Tank ft; ft; ft C 10 pts C 9 pts C5 pts <br /> 0 if 0 if 0 if <br /> R ondition R conditi on R ondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> ini mum Depth to groundwater from the Soil Sample (feet) ?D_z_ >100 1-100 25-5011 <br /> Fractures in subsurface (applies to foothills or mountain areas) Io None Unknown resent <br /> verage Annual Precipitation (inches) xxxxxx 00 9 10-25 xxxxmx 26.40E <br /> Ian-Made conduits which increase vertical migration Q <br /> f leachate (i.e., septic systems, water wells, ponds) None l Unknown resent <br /> nique site features: Recharge area, coarse soil, nearby wells. n At least 4ore than <br /> xxxxx None I'll one one <br /> COLUMN TOTALS>>>TOTAL POINTS ID + 24 + 4z. <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS F9 pts or more 41 - 48 pts 40 pts or less <br /> ND B T E B T E <br /> -5 pig M)VVV MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NAL <br /> ample Result: ASOLINE 1000 100 10 <br /> YY AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> Jb TPH}pp�(j 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 /> 11 If depth is > 5 ft, and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> -L2 If precipitation is > 40 inches, score 0 points. <br /> 13 Levels for BTXBE are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION D- 3 (S z--1 1 <br /> 1. <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes I IN01 <br /> a,3 Ppb 1, j-TriUnloipetha" <br /> 2. Recommend Site Closure as I �o I �If Yes, Refer to Site Mitigation for Evaluation q4,ppb TrnGhluroether�c. <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR D�3� 5` f�P(=�Trtchla-cetW� <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF )) � � � <br /> VALUATOR rkl i1 t vut/ <br /> EH 23 80 (UGTWKSHT)\5/90 <br />