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H <br />AME OF FACILITY ' <br />OORESS 93 2.P <br />TANK SIZE Qti� ' fu <br />SAN JOAO :TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H 3 VISION <br />UST WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br />�_s / ECORD ID y <br />[TANK ID# 3 /-'(® 1� 1 <br />JEL TYPE 14" -a D' -t,► <br />permit current7 es o ermit # - acility Status Code oc.Soil/GW Cont es o <br />nber of Tanks at facility kge of Tank(if available)Type of Tank tee[ Fbrgl ngl Dual <br />ill. TANK HISTORY <br />�as Tank tested? <br />es <br />o <br />ailed precision test ? <br />es <br />I <br />o <br />verage Annual Precipitation <br />If yes, give date(s) <br />as a repair made to the tank system? es No 1 11f yes, what was repaired7 <br />as repair done under inspection? es No ere soil samples analyzed7 es o <br />TXE PH -G PH -D b/EDB <br />Type of failure/discharge <br />Irr <br />atastrophic long-term leakage <br />E <br />lo—rfiIt <br />S <br />C <br />0 <br />R <br />E <br />nown <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 />es <br />o <br />epth to Ground Water <br />' <br />of/Year <br />verage Annual Precipitation <br />On -Site Well(s)Yes oi <br />Number & Type <br />Irr <br />am ub <br />S <br />Score <br />10 pts <br />if <br />ondition <br />is met <br />S <br />C <br />0 <br />R <br />E <br />Score <br />9 pts <br />if <br />condition <br />is met <br />S <br />C <br />0 <br />R <br />E <br />core <br />pts <br />f <br />ondition <br />s met <br />istance to Well(s) from Tank ft; ft; ft C <br />0 <br />R <br />:. Site Feature - Leaching Potential Analysis E <br />Minimum Depth to groundwater from the Soil Sample (feet) <br />>100 <br />1-100 <br />( <br />25-50\1 <br />Fractures in subsurface (applies to foothills or mountain areas) <br />None <br />Unknown <br />Dresent <br />verage Annual Precipitation (inches) KXXXXX <br /><10 <br />9 <br />10-25 <br />xxxxxxx <br />26-40L <br />an -Made conduits which increase vertical migration <br />f Leachate (i.e., septic systems, water wells, ponds) <br />None <br />Unknown <br />resent <br />nicue site features: Recharge area, coarse soil, or wells. <br />CMurcipal=>2000 ft; domestic=>500 ft; irr/agricultural=present) xxxxxx <br />None <br />�j <br />/ <br />At least <br />one <br />ore than <br />one <br />COLUMN TOTALS>>>TOTAL POINTS <br />7,71 <br />3 2 -- <br />ample Result: (B T X OR E) <br />RANGE OF TOTAL POINTS 9 pts or more <br />41 - 48 pts <br />40 pts or less <br />B T X E <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) 1 50 50 50 <br />B T IX E <br />3 .3 1. 1. <br />NA13 <br />ample Result: J� 176D(jj SOLINE 1000 <br />77) AXIMUM ALLOWABLE TPH LEVELS (PPM) <br />+-r=`'�H �t4. IESEL 10,000 <br />100 <br />10 <br />1000 <br />100 <br />OOTNOTES: ***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 />L If precipitation is > 40 inches, score 0 points. <br />\3 Levels for 8TX&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. Reco=end Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br />VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISO LEAD SENIOR <br />CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES K 0 EFERRED TO SITE MITIGATION FOR EVALUATION rES ` 0 <br />ATE REFERRED ATE CLOSURE LETTER MAILED <br />AME OF <br />VALUATOR <br />EH 23 80 (UGTWKSHT)\5/94 <br />l t�.B <br />