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SAM JOAOOIN Cr M PUBLIC HEALTH SERVICES/ENVIRONMENTAL Hi DIVISION _ <br /> L. T WORKSHEET FOR SITE CLOSURE EVALUATION - - DATE — <br /> NAME OF FACILITY L P F( k M 1 EPS CODE G <br /> ADDRESS Lf/ S TANK ID C <br /> TANK SIZE 0015 1 FUEL TYPE Ut'� <br /> 11. GENERAL SITE HI TORY <br /> Is permit current? Yes No I N�Permit C - Facility Status Code Ooc.Soil/GW Cont Yea No <br /> Number of Tanks at facility Age of Tanks(if avaitable) Type of Tank Steel Fbrgl Sngl Dual <br /> 111. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test ? Yes No If yes, give date(s) <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? <br /> Was repair done under inspection? Yes No Were soil samples analyzed? Yes No BIKE TPH-G TPH-D Pb/EDB <br /> Type of failure/discharge) catastrophic long-term leakage overfill uiknowm other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Ground Water ✓- ef/Yesr T-_ Average ArruaL Precipitation A- 14 10-25 <br /> On-Site WeLL(s) Yes No Number & TypeIrr Dom Pub <br /> S Scare 5 Score S Score <br /> Distance to WeLL(s) 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 iti on <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet) >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None X Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 Ixxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) None Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> xxxxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS + + <br /> Sample Result: (S T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> p, m 2s <br /> de , MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) B 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Rpul GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH DIESEL 10,000 1000 100 <br /> FOOTNOTES: —If documented soil and/or ground water contamination is present, do rat complete the Leaching 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 depth <-5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTX&E are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <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 Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> i <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE IVES ­IN REFERRED TO SITE MITIGATION FOR EVALUATION YES NO L <br /> DATE REFERRED / / DATE CLOSURE LETTER NAILED <br /> NAME OF <br /> EVALUATOR �) <br /> EH 23 80 (UGTWKSHT)\5/90 <br />