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SAN JOATI" ANTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL °"- tH DIVISION <br /> 1• GST WORKSHEET FOR SITE CLOSURE EVALUATIOA DATE Tj�i/8/C��Q� <br /> NAME OF FACILITY v. L:� SWEEPS CODE /Cyb -a <br /> ADDRESS Tp TANK ID # - <br /> TANK SIZE /pr-xZl. FUEL TYPE <'��- <br /> 11. GENERAL SITE HISTORY <br /> **r <br /> Is permit current? Yes No Permit # - Facility Status Code DOC.$e1L/GW Cont Yes No <br /> Number of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Duel <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 BTXE TPH-G TPH-O Pb/EDB <br /> Type of failure/discharge catastrophic long-term leakage overfill unkrwwn 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 a Ref/Year Average Annual Precipitation A= 14 10-25 <br /> On-Site Well(s) Yes No Number & Type Irr Dom Pub <br /> S Score S Score S Score <br /> Distance to Nell(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 condition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> Minimum Depth to groundwater from the Soit SampLe (feet) / >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None 01Unknown Present <br /> Average Annual Precipitation (inches) XXXXXX <10 9 10-25 xxxxxxx 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 + + = ZfI <br /> Sample esu t: (B X 9R ) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pis 40 pts or Less <br /> B T X E a T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA13 <br /> Sample Result: ,.� GASOLINE 1000 100 10 <br /> 450 9"` - MAXIMIM ALLOWABLE TPH LEVELS (PPM) <br /> O #A TPH-,D DIESEL 10,000 1000 100 <br /> FOOTNOTES: *"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 /> \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 1100 ppm (diesel). <br /> VI. 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 COM LETED BY A SUPERVISOR/ ENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / ` DATE CLOSURE LETTER MAILED <br /> NAME OF W <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />