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SAN JOAWI► TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H; :VISION <br />I, UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE 1 <br />AME OF FACILITYI UL -10 colf -40 nn ECORD ID <br />DDRESS '7 .,7 s`) / 1_ I . /' — !/_ _ _ WK ID # <br />II. GENERAL SITE HISTORY <br />Is permit current? es o i <br />Number of Tanks at facility <br />III. TANK HISTORY <br />t # I - IFaciLity Status Code poc.Soil/GW Cort Les I r <br />ge of Tank(if available) ype of Tank tecl I jFbrgl ngl I Dual <br />as Tank tested? <br />es <br />K <br />IHOI <br />ailed precision test ? <br />as <br />of/Year <br />o <br />If <br />yes, give date(s) <br />as a repair made to the tank system? es No <br />f yes, what was repaired? <br />es <br />as repair done under inspection? <br />es dere soil samples analyzed? <br />es <br />umber & Type <br />o <br />TXE <br />PH -G <br />PH -D <br />b/EDB <br />ype of failure/discharge <br />atastrophic long-term leakage <br />verfill <br />known <br />I <br />lother: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />oil Samples Received <br />as <br />I <br />IN01 <br />epth to Ground Water <br />of/Year <br />op <br />verage Annual Precipitation <br />n -Site WeLL(s) <br />es <br />o <br />umber & Type <br />Irr <br />om <br />ub <br />S <br />core <br />10 pts <br />S <br />C <br />Score <br />9 pts <br />S <br />C <br />Score <br />5 pts <br />istance to WeIL(S) from Tank <br />ft; ft; ft C <br />0 <br />if <br />ondition <br />is met <br />0 <br />R <br />E <br />if <br />condition <br />is met <br />0 <br />R <br />E <br />if <br />ondition <br />is met <br />R <br />V. Site Feature - Leaching Potential Analysis E <br />inimum Depth to groundwater from the Soil Sample (feet) <br />>100 <br />1-100 <br />25-50\1 <br />Fractures in subsurface (applies to foothills or mountain areas) <br />None <br />C? <br />Unknown <br />Dresent <br />Average Annual Precipitation (inches) xxxxxx <br /><10 <br />9 <br />10-25 <br />KXXXXXX <br />26-40_2, <br />an -Made conduits which increase vertical migration <br />q <br />f leachate (i.e., septic systems, water wells, ponds) <br />None <br />! <br />Unknown <br />resent <br />pique site features: Recharge area, coarse soil, or wells. <br />q <br />At least <br />4ore than <br />[Muncipal=>2000 ft; domestic=>500 ft; irr/agricultural=present] KXXXXX <br />None <br />/ <br />one <br />one <br />3 ?-- <br />COLUMN TOTALS» -TOTAL POINTS <br />+ <br />ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more <br />41 - 48 pts <br />40 pts or less <br />B <br />X <br />E <br />B T X E <br />MAXIMUM ALLOWABLE B-T-X•E LEVELS (PPM) 1 50 50 50 <br />.3 <br />JT <br />.3 <br />1. <br />1. <br />NAS <br />ample Result: <br />ASOLINE 1000 <br />100 <br />10 <br />AXIMUM ALLOWABLE TPO LEVELS (PPM) <br />TPH <br />IDIESEL 1 10,000 <br />1000 <br />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., 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 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 />VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR a <br />CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE fES 0 EFERRED TO SITE MITIGATION FOR EVALUATION fES <br />ATE REFERRED / / ATE CLOSURE LETTER MAILED <br />AME OF <br />VALUATOR <br />EH 23 80 (UGTWKSHT)\5/94 <br />