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SAN JOAC SL HTY <br /> PUBLIC HEALTH Sc VICS/EXVIRONMEr1T0 *7H DIVISION <br /> (. UGST WORXSHET FOR SITE CLOSURE EVALUAT DATE( <br /> ;NAME OF FAC.LI T' I �,\I� ISWEEPS =EI ld <br /> ,ADORESSILANK ID I J? D3 <br /> (TANK SIZE! r, (FUEL YPEi <br /> !i. GENERAL Siic HISTORY 1 _ <br /> iIs permit current? Yes INoI (Permit .I - (Facility Status Codel IDoc.SaiL/C.1 Cont Yes INoI <br /> (Number of Tants at facility (Age of Tanks(ifi available)( l 110�IType or TankjSteeII/IFbrgl ISngII Dua() <br /> al � <br /> iiI. TANK HISTORY <br /> Inas Tank tested?IYesl INoI Failed precision test ?IYesl INoI 11f yes, give date(s)I <br /> Was a repair made to the tank system? Yesl Nol lIfi yes, what was repaired?I � <br /> ;was repair done under inspection?`Yes INoI (Were soil samotes analyzed? YesINoI NS-,XEI yITPH-GI ) 'M H-DI Pb/EDB ; <br /> Type of failure/discharge) (catastrophic) (long-term leakagerfi <br /> ) )ovell) Iunknownl (other: nnn � /1\ j <br /> IV. REMOVAL HISTORY (A—MACH INSPECTION REPORT FOR SITE DETAILS/COLLE= DATA FOR LEACHING POTENI1AL ANALYSIS) <br /> Soil Saaples ReceivedlYesl INo1 IDeoth to Ground water) IRef/Yearl, ;19$ Average Annual Precipitation A=114 110-25! <br /> i <br /> !On-Size WeLICs)iYes I INoI INumoer & Type Irrl IDomI IPumI S Scare S Scare S Scare <br /> `:Distance to Well(s) from Tank) ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if C it 0 if <br /> R condition R condition R condition <br /> ;V. Site Feature - Leaeiing Potential Analysis C is met 'c is met E is met <br /> ;Minimum Depth to groundwater from the SoiL Sample (feet) II I >100 I 151-100 I 125-50\1 <br /> (Fractures in sccsur�ace (aoplies to foothiLLs or mountain areas) I None 1 1 Unknown I (Present <br /> Average Annual Precipitation (inc—nes) 1===x1 <10 1 9 10-25 lxxx== 26-40\2 <br /> )Mart-Made conduits which increase vertical migration <br /> hof leachate (i.e-, septic systems, water weLLs, ponds) I I None I Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearvy wells. I At Least More than <br /> I <br /> 1=,= None I I one one j <br /> COLUMN TOTALS»>TO'TAL POIN75 <br /> Samote Result- CB T X OR E) RANGE OF TOTAL POINTS 49 pts or marc I 41 - 48 Pts 1 40 pts or Less <br /> -r- ,►SSa D �'oO PP B T X 'c B T X 'c <br /> ray p 1p�� MAXIMUM ALLOWABLE B-T-X-E L.eYEiS (PPM)) 1+ 50) 50, 50 I .5. I-3 I <br /> 1. 1. NA\3 <br /> Sample Result_ GASOLINE( 1000 I 100 i 10 <br /> I <br /> "'too tpi6 'rPN P MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> D IESc, 10,000 1 1000 l 100 <br /> (FOOTNOTES: "`'If documented soil and/or ground water contamination is present, do not complete the Leacdting potential <br /> analysis. (i_e., site is currerrtLY of UGT Contaurirtation List for sail or ground water.) <br /> \1 If depth is > 5 ft. and < 25 ft-, scare 0 points. if depth <=5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, scare 0 points. <br /> \3 Levels for BTX&E are not appLicanle at a TPH concentration cf 10 ppm (gasoline) or 100 ppm (dieseL). <br /> VI. STAFF REC.MMENDATION/CONCLUSION <br /> j 1. Are BTX & E or TPH Concentrations > Allowable Levels 1--fes! X INoI <br /> � 2_ Recommend Site Closure Yes No 1"Ifi Yes, Refer to Site Mitigation for Evaluation <br /> T <br /> VII. REVIEW EVALUATION - TO BE =MPLE710 BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE FOR <br /> 1NO) 1RErcRRED TO SITE MITIGATION FOR EVAWATIONI7ESI�SIOI 1 <br /> DATE 2E= RcJ' /2 / (DATE CLOSURE L:,!R M � <br /> AILI <br /> NAME OF <br /> EVALUATOR <br /> E9 23 80 (UG7WXSNT)\5/90 <br />