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SAN JOADUIV "TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL I ./DIVISION <br /> T WORKSHEET FOR SITE CLOSURE EVALUATION DATE 4_ <br /> NAME OF FACILITY d— �r•l'- * SWEEPS CODE 1 <br /> ADDRESS 3 JJ TANK ID #13 ? -2_241 -2, <br /> TANK SIZE FUEL TYPE D I ecA4SY'OGK ( I es <br /> II. GENERAL SITE HISTORY `� r I `S P� <br /> Is permit current? Yes No Permit # - Facility Status Code Doc.Soil/GW Cont Yes No <br /> Number of Tanks at facility Age of Tanks(if available) 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 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 Water Ref/Year Average Annual Precipitation A= 14 10-25 <br /> On-Site WeIL(s) Yes No Number 8 Type Irr Dom Pub <br /> G Score s score S Score <br /> Distance to W@LL(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if O 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) >100 51-100 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, 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: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more - 48 pis 40 pts or Less <br /> sP1 - qu tv1) <br /> P77 5 �I I N 1 T X E B T X E <br /> r P 14AXIMLM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Res Lt: GASOLINE 1000 100 10 <br /> '�11 - N / MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> 5 J TPH D DIESEL 10,000 1000 100 <br /> FOOTNOTES: **-If documented soil and/or ground water contamination is present, do t c 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 BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION TiQD/S "'� pi / n <br /> 1. Are BTX 8 E or TPN Concentrations > Allowable Levels *Yes No V <br /> 2. Recommend Site Closure Yes No If Yes, Refer to Site Mitigation for Eva Luati <br /> x1_ an <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATIONYES NO <br /> DATE REFERRED �/ `✓4 / DATE CLOSURE LETTER 14AILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />