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t SAN JOAG!' ,TY PUBLIC HEALTH SERVICES/ENVIRCNMENTALIF DIVISION <br /> } I. � UGST WORKSHEET FOR SITE CLOSURE EVALUATIQ DATE C <br /> NAME OF FACILITY / L� J SWEEPS CODE 3_�3 C� <br /> ADDRESS C3 �'� 1 L: TANK {D <br /> TANK SIZEl 3 O� G (FUEL TYPE ]�/ <br /> �-` <br /> II. GENERAL SITE HISTORY <br /> Is permit current? Yes No Permit � <br /> p l Facility Sratus Code L'Dcc.S,0iL/GW Cont Yes NaHumber of Tanks at facility Age of Tanks(if available) Type of Tank <br /> ngL Dual <br /> If I. TANK HISTORY <br /> Was Tank tested? Yes i X <br /> No Failed precision test ?:Yes No if yes, give date(s) <br /> Was a repair made to the tank system? Ye If yes, what was repaired?I <br /> s Nal I <br /> Was repair done under inspection? Yes No Were sail samples analyzed?IYes No BTXE ITPH-GI ITPH-DI IPb/ED8 <br /> Type of failure/discharge catastrophic Long-term leakage loverfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR.LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yesl No Depth to Ground Water,56 Ref/Year EL Average Annual Precipitation A=114 10-25 <br /> On-Site Wel[(s) Yes No Number & Type Irrl Dom Pub <br /> S Score S Score 5 Score <br /> Distance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R condition R condition R condition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> lMinimum Depth to groundwater from the Soil Sample (feet) <br /> ,)6.— >100 l �51-100 I r 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) rNone Unknown Present <br /> Average Annual Precipitation (inches) xxxc !e10 9 110-25 lxxxxxxxl 25-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) None unknown I (Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At Least More than <br /> xxxxxxi:None one <br /> COLUMN TOTALS»>TOTAL POINTS <br /> Sample Result: (3 T X OR E) RANGE OF TOTAL POINTS 49 pts or more' 41 - 48 pts 40 pts or less <br /> r� <br /> 7aWs IV D� O B TX EB T x E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50' 3 3 1. 1. NA\3 <br /> il 1 l i <br /> Sample Result: GASOLINE 1000 100 10 <br /> 8'0 MAXIMUM ALLOWABLE TRH LEVELS (PPM) <br /> 1" TPH DIESEL 10,Q00 1000 l 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, d eaching 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 depihi< 5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> j \3 Levels for 8TX&E are not applicable at a TPH concentration Laf 10 ppm (gasoline) or 100 ppm (diesel), <br /> I °t <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> Jif c i n <br /> 1. Are BTX & £ or TPH Concentrations > Allowable Levels *Yes INa �, <br /> 2. Recommend Site Closure Yes No if Yes, Refer to Site Mitigation for Evaluation �LGG 777777 <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR Il <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YESNO (REFERRED TO SITE MITIGATION FOR EVALUATION YES NOI <br /> DATE REFERRED / / KATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWICSHT)\5/90 <br />