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SAN JOAOGIIr-#TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE1 DIVISION <br /> I. ST WORKSHEET FOR SITE CLOSURE EVALUATION DATE -?1,131-7 <br /> NAME OF FACILITY �!-10'�/ ! SWEEPS CODE /&> <br /> ADDRESS .J OPo A TANK ID # -Z I <br /> TANK SIZE 6 FUEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? Yes V\I <br /> No Permit # Facility Status Code Dac.Soil/GW Cont Yes LKI <br /> Number of Tanks at facility Age of Tanks(if available) (Type of Tank l Steell lFbrgll lSngl Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test 7 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-D Pb/EDB <br /> Type of failure/discharge catastrophic Long-term leakage overfill unknown 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 Water35 Ref/Yes �b Average Annual Precipitation A= 14 10-25 <br /> On-Site Wett(sd Yes No Number & Type Irr Dam Pub <br /> S Score 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 condition <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) 2 >100 51-100 O 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown 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, prods) 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 + + = J� <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> g: rj.O.;.wSgN0-.olb�Iti <br /> -r-14.Ion•.OD5#' B T X E B T X E <br /> 7n` . 0'17/7/!-, MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 501 501 50 .3 .3 1. 1. NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> 23o TPN—p DIESEL 10,000 1000 10 <br /> FOOTNOTES: •*•!f documented soil and/or ground water contamination is present, do not complete the Leeching 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 (gas^otine) or 100 ppm (diesel). <br /> VI. STAFF 2ECOMMENOATION/CONCLUSION v�F > <br /> 1. Are BTX & E or TPH Concentrations > ALLouebte Levels -Yes No v <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 /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE IYES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED H /-r !DATE CLOSURE LETTER MAILED / / <br /> NAME OF ' <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />