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SAH JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br />'WORKSHEET FOR SITE CLOSURE EVALUATION DATE )/ _,I2 _ <br />NAME OF FAOfL1TY \ n I N - - / u / <br />ADDRESS 3 <br />(TANK SIZE FUEL TYPE oitr -"f <br />1. GENERAL SITE HISTORY *.• <br />Is permit current? Yes o Permit # - Facility Status Code �� Ooc.Soil/GW Cont Yes] N <br />iNumber of Tanks at facility `Z_. Age of Tanks(if available) L'/0/ Type of Tank Steel brgl Sngl Dual <br />Was Tank tested? <br />YesNo <br />..._. <br />__.___ <br />Failed precisiootestTesl <br />No <br />f <br />yes, give dates)Was <br />a repair glade to the tank system? <br />Yes <br />N, <br />what was repaired?Wasrepair <br />done under inspection? <br />Yes <br />Ref /year <br />No <br />Average Arcual Precipitation <br />samples analyzed? <br />Yes <br />10-25 <br />No <br />Yes <br />TXE <br />No <br />TPN-GType <br />Number & Type <br />Irr <br />Dom <br />of failure/discharge <br />Pub <br />catastrophic <br />S <br />C <br />loage <br />S <br />C <br />overfill <br />unknown <br />Distance to well(s) from Tank <br />other: <br />IV REMOVAL HI <br />cnnoT CID CTTF nFT111s/C0LLEC1 UAIA rVK LLAlminw rrv,vni,n. ..••... _•_, <br />­ '. .,.. <br />..._.. <br />..._. <br />__.___ <br />__ <br />Soil Samples Received <br />Yes <br />No <br />Depth to Ground Water <br />`� <br />Ref /year <br />��; <br />Average Arcual Precipitation <br />A= <br />14 <br />10-25 <br />On -Site WeLL(s) <br />Yes <br />No <br />Number & Type <br />Irr <br />Dom <br />Pub <br />S <br />C <br />Score <br />10 pts <br />S <br />C <br />ScoreLR <br />9 ptsts <br />re <br />Distance to well(s) from Tank <br />gji ft; ft; ft <br />0 <br />R <br />E <br />if <br />condition <br />is met <br />0 <br />R <br />E <br />if <br />condidition <br />is memet <br />V. Site Feature - Leaching Potential Analysis <br />Minim m Depth to groundwater from the Soil Sample (feet) <br />>100 <br />- <br />51-100v <br />25-50\1 <br />Fractures in subsurface (applies to foothills or mountain areas) <br />O <br />None <br />-� <br />Unknown <br />— <br />Present <br />xxxxxx <br /><10 <br />9 <br />10-25 <br />xxxxx:cx <br />26-40\2 <br />Average Annual Precipitation (inches) <br />Man -Made conduits which increase vertical migration <br />O <br />None <br />_ <br />Unknown <br />Present <br />of leachate (i.e., septic systems, water wells, ponds) <br />Unique site features: Recharge area, coarse soil, nearby wells. <br />None <br />/yt <br />v( <br />At least <br />one <br />_ <br />More than <br />one <br />x�x7xxxx <br />L C <br />} <br />COLUMN TOTALS>>>TOTAL POINTS <br />Sample Result: IS T X OR E) <br />RANGE OF TOTAL POINTS <br />49 pts or more <br />41 - 48 pts <br />40 pts or less <br />B <br />T <br />X <br />E <br />a <br />T <br />% <br />E <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) <br />1 <br />50 <br />50 <br />50 <br />.3 <br />.3 <br />1. <br />I <br />1. <br />NA\3 <br />GASOLINE <br />1000 <br />100 <br />10 <br />Sample Result: <br />10,000 <br />1000 <br />100 <br />MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br />TPN <br />DIESEL <br />FDOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the leaching potential <br />water.) <br />analysis. (i.e., site is currently on UGT Contamip�ation List for soil or ground <br />\1 if depth is > 5 ft. and < 25 ft., score 0 points. If dep1.M <=5 ft., do not use table. <br />\2 If precipitation is > 40 inches, score 0 points. ppm ppm (diesel). <br />of 10 (gasoline) or 100 <br />\3 Levels for BTX&E are not applicable at a TPN concentration <br />V1. STAFF RECOMMENDATION/CONCLUSION <br />1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No <br />2. Recommend Site Closure Yes No *If Yes, Refer to Site Mitigation for Evaluat <br />WI.oc 'Wool CTRn RY l RIIGFRVISOR/SENIOR <br />R WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION <br />REFERRED / / DATE CLOSURE LETTER MAILED <br />OF <br />EH 23 80 (UGTWKSHT W,S 0 <br />