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SAH JOAQUIN COUH JBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH(JSIOH <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AHE OF FACILITY / N f EPS COOS <br /> --QEsS 15%,13- 5. -77-! Aux ID x - /sb <br /> SIZE C1/L EHE <br /> /eG dads <br /> i <br /> ;E. GENERAL SITE HISTORY <br /> fs permit current? ts a ermit # O - /�J 3 <br /> acIIIty Status Code oc aiL Cont es o <br /> r of Tanks at citity a ge of Tanks(if available) 4[f A) ype of Tank Leet brgt ngl Dvat <br /> i <br /> l71. TANK HISTORY <br /> s Tank tested? es 7 o ailed precision testes o If yes, give dates) <br /> kas a repair made to the tank system? es No I L111f yes, what was repaired? <br /> s repair done under inspection? es qo ere soil samples analyzed? es a TXEPH-G PH-0 b/EDS <br /> ype of failure/discharge atastrophic long-tern leakage verfill cher: <br /> :7. REMOVAL HISTORY (ATTACH INSP TION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oit Samples Received es o epth to Ground Water C-' of/Year verage Annual Precipitation = 4 0-25 <br /> i <br /> Site Wells) IYes 1 o Lviunber & Type F Irr <br /> S Score 5 I Score S core <br /> istance to Wett(s) from Tank ft; ft; ft C 10 pts C 9 pts C pts <br /> 0 if 0 if o f <br /> R zoriodition R condition R ordition <br /> Site Feature - Leaching Potential Analysis E 's met E is met E s met <br /> L . <br /> inimtm Depth to groundwater from the it Sampte (feet) >100 1-100 25-50\1 <br /> ractures in subsurface (applies to foothills mountain areas) Hone Unknown 3resent <br /> ge Annual Precipitation (inches) <1 9 1 5 xxxxxxx 26.40\2 <br /> n-Made conduits which increase vertical migration <br /> f Leachate (i.e., septic systems, water wells, ponds) "'T e Unknown 2resent <br /> ' 4 C ique site features: Recharge area, coarse soil, nearby wells. At least ore than <br /> xxx one one <br /> COLUMN TOTALS—TOTAL POINTS • <br /> le Result: (9 T X OR E) RANGE OF TOTAL POINTS 9 pts or mate 41 - 48 pts 40 pts or less <br /> S T XItO <br /> B T X E <br /> MAXTMLH ALLOWABLE B-T-X-E LEVELS (PFM) 1 50 50 .3 .3 1. 1. NA\3 <br /> i <br /> Pamp <br /> Le suit: SOLIHE 1000 100 10 1 <br /> 1MRH ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> TNOTES: f documented soil and/or ground water contamination is presenc,� o not complete the leaching potential <br /> anatysis. (i.e., site Is currently on UOT Contaminat I onLjIst for soil or ground water.) <br /> \1 If depth is > 5 ft, and < 25 ft., scare 0 points. If depth <=5 do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \.3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> 91- STAFF RECOMENDATION/CCHCLUSION <br /> 1 <br /> I. Are 9TX ESE or TPN Concentrations > AltowaSLe Levels Yes o <br /> 2. Recommend Site Closure IYes o If Yes, Refer to Site Mitigation for Evaluation <br /> V11.'REVIEV EVALUATION - IO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> YITN STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATICH FOR EVALUATICN ES 0 <br /> f <br /> x <br /> TE REFERRED C ATE CLOSURE LETTER HAILED <br /> ALUATOR � ` -.•. `. . � <br /> Ea 23 80 (UCTWKSHT)\5/90 <br />