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SAN JOACUIH CL�.,,T 8LIC HEALTH SERVICES/ENVIRCNKENTAL HEAL D SION _ <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATICH ATE <br /> AME OF FACILITY , '' EEPS CODE f ' <br /> ANK IO # �' -f� <br /> nORESS <br /> IANK SIZE d UEL TYPE 7�t,-n , <br /> I. GENERAL SITE HI CRY ww <br /> I <br /> E <br /> t eurrerC7 es a ermit # - acit(ty status Cade WI ! <br /> an[ es o <br /> of Tanks at facility ge of Tanks(if available) ype of Tank tengl Dual <br /> 1 <br /> 11. TANK HISTORY <br /> ns Tank tesied7 es o ailed precision test ? es o If;yes, give dates) <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> P <br /> as repair done under inspection? es a ere soil samples analyzed? es o 1XE PH G PH D 4/EDB <br /> ype of failure/discharge atastrophic long term leakage verfill nknown Cher: <br /> I V. REMOVAL HISTORY (ATTACH IHSPT[ON REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> f <br /> oil Samples;Received es a epth to Graund Vater ' of/Year )ondition <br /> verage Arnuat PrecipitatiSite Wells) es o ember S Type Irr om ubScore S care 5 core <br /> istance to Wells) from Tank ft; ft; ft C0 pts C pts C pts <br /> 0- f 0 if 0 f <br /> R R ondition R ordition <br /> . Site Feature - Leaching Potentiat Analysis Es met E is met E s met <br /> inimum Depth to groundwater from the Soil Sample (feet) �� —/` >100 1 100 �15 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) Q None Unknown 5resent <br /> %vcrage Annual Precipitation (inches) xxxx <10 9 10-25 xxxxxxx 26.40\2 <br /> an-Made conduits which increase vertical migration <br /> F teachate :(i.e., septic systems, water wells, ponds) Hone Unknown resenC <br /> nique site features: Recharge area, coarse soil, nearby wells. /y At least 4are than <br /> xxzx None / one one <br /> F 7� <br /> COLUMN TOTALS»>TOTAL POINTS V t Fs, <br /> ampte Result: (8 T x OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> k <br /> �D B T X E B T x E <br /> MAXIMUM ALLOWABLE $-T-X-E LEVELS (RPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> �i ample Result: ASOLINE ]000 100 ]0 <br /> Re AXIAUM ALLOWABLE TPH LEVELS (PPM) <br /> IV D TPN IDIESEL I 10,OCO 1000 100 <br /> FOOTNOTES. wwwlf documented soil and/or ground water contamination is :present, do not complete the leaching potential <br /> arwtysis. (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 /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for 8TX&E are not applicable at a TPH concentrarion of 10 ppgm (gasoline) or 10Q ppm (die_sel).. <br /> i STAFF RECOW5NDATION/CCNCLUSIONa'4j'fz -*y" �cS .�GC�L Qw Q' <br /> ]. Are BTX d E or TPH Concentrations > Atto able Levels Yes <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> { <br /> I. REVIEW EVALUATION - TO BE CCMPLETED BY A SUPERVISOR/SENIOR <br /> i <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE VES O EFERRED TO SITE MITIGATION FOR EVALUATICN ES ❑ <br /> r <br /> ATE REFERRF )ATE CLOSURE LETTER MAILED f / <br /> LAME OF <br /> :VALUATOR <br /> EH 23 80 (VGTVK5HT)\5/90 <br /> F i <br />