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S rr <br /> f l_ <br /> SAN JOA ,0UNTY PUBLIC HEALTH SERVICES/ENVIRONMENTA'r ALTH DIVISION <br /> T. UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE -7- 5 <br /> AME OF FACILITY } '���//[/n� )4 ! 1 ' f f r -� - ECCRO ID 3 "' <br /> ADDRESS ��,.` r L'l AkK ID /,;4 <br /> ANK SIZE I ��_ UEL TYPE <br /> 11. GENERAL SITE HISTORY / <br /> Is permit current? es 0 ermit X - f 4� acility Status-Code [ oc.Soil/GLI Cont es qo <br /> umber of Tanks at facility kge of Tank0 f available) ' ype of- Tank teel Fbrgt ngl Dual <br /> 111. TANK HISTORY vim» <br /> as Tank tested? es Ko ailed precision test ? es a If yes, give date(s) <br /> Jas a repair made to the tank system? es No 11f yes, ghat was repaired? <br /> as repair done under inspection? es a 1 ere soil samples analyzed;' es a I TXE I PH-G PH-0 b/EDB <br /> Type of failure/discharge atastrophic long-term leakage verfiil the,; <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> So il Samples Received es o epth to Ground Water 1040ef/Year 15>6 verage Annual Precipitationrandition <br /> n-Site Wells) es o umber & Type 11 rr om <br /> S care S core S <br /> istance to Welts) from Tank ft; _f t; ft C 0 pts C pts C <br /> 0 if 0 if 0 <br /> R ondition R condition R Site Feature - Leaching Potential Analysis E -s metE is met E <br /> inimexn Depth ro groundwater from the Sail sample (feet) ®•— >100 1-100 25-50L1 <br /> I <br /> ractures in subsurface (applies to foothills"or mountain areas) None Unknown resent ' <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 xxxx 26-40L ' <br /> an-Made conduits Which increase vertical migration <br /> f leachate O.a., septic systems, water wells, Ponds) ( None Unknown resent <br /> nidue site features: Recharge area, coarse sail, or wails. At Least ore than <br /> (MuncipaL=>2000 ft; domestic=>500 ft; irr/agricuitural=present] xxxxxx Hone 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 pts or Less <br /> T X JE B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) I 50 50 50 .3 .3 1.• 1- NAL <br /> Sample Result: GASOLINE 1000 100 - l0 <br /> AXIMUM ALLOWABLE TPH 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 thing potentia! <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground wa <br /> 11 If depth is > 5 ft. and < 25 ft., score 0 points. 1f depth =5 ft., do net use table. <br /> ]2 If precipitation is > 40 inches, score 0 points_ <br /> N3 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). i <br /> Vt. STAFF RECOMMENDATION/CONCLUSION Y I <br /> 1. Are BTX & E or TPH Concentrations > Aitowabte Levels es 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 <br /> F" <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ESC) <br /> EFERRED TO SITE MITIGATION FOR EVALUATION ES ❑ € <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTUKSHT)\5/94 <br /> " I <br />