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SAN JOAOU NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL iX DIVISION <br /> 1. '--dGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE — <br /> NAME OF FACILITY SWEEPS CODE <br /> ADDRESS ,3133 -f- TANK I0 # - J7 K -.3 <br /> TANK SIZE FUEL TYPE w !' 0 1 j <br /> wS C- P lir <br /> 11. GENERAL SITE HISTORY <br /> e.. <br /> Is permit current? Yes No Permit # - Facility Status Code1 Doc.Scil/GW Cant Yes No <br /> (Number of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgll Sngl Dual <br /> III. TANK HISTORY <br /> Was Tank tested?IYes No Failed precision test ? Yes No If yes, give date(s) <br /> (Was a repair made to the tank system?IYes No If yes, what was repaired? <br /> 1 Was repair done under inspection? Yes No HWere soil samples analyzed? Yesl No BTXE I TPH-G TPN-D Pb/EDBI <br /> Tpe yof 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/YearI Average Annual Precipitation A=I 14 110-25 <br /> On-Site WeLI(s) Yes No Number & Type Irr Dual Pub <br /> S Score S Score 5 Scare <br /> Distance to WeM 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 /> 1V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> i <br /> Minimum Depth to groundwater from the Soil Sample (feet) >100 1 151-100 1 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown Present <br /> (Average Annual Precipitation (inches) xxxxxx 00 i 9 1 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 we one <br /> COLUMN TOTALS>»TOTAL POINTS <br /> 1 Sample Result: (B T X OR X11 RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pis 40 pts or less <br /> �O7b <br /> X - B T X E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sa ^mple Result: (GASOLINE 1000 100 10 <br /> F MAXIMUM ALLOWABLE TPX LEVELS (PPM) <br /> ff V TPN Y DIESEL 10,000 1000 IL 100 <br /> FOOTNOTES: —If documented sail and/or ground water contamination is present, da aching potential <br /> analysis. (i.e., site is currently on LAST 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 TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION _7G r13'_S tr/rC l�Q,p� <br /> LLJJ Gt.P�.bW Le.PJ'e2�G.0DJr. <br /> 1. Are BTX 8 E or TPN Concentrations > Allowable Levels_ `Yes 11 7No 11-rzsteol <br /> 2. Recommend Site Closure Yes No If Yes, Refer to site Mitigation for Evaluation) put2A - <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVTSOR/SENIOR C ,�� Ag, � . <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE(YES NOI (REFERRED TO SITE MITIGATION FOR EVALUATIONI7E5 NO <br /> DATE REFERRED( / / DATE CLOSURE LETTER NAILED <br /> NAME OF <br /> EVALUATOR <br /> EN 23 80 (UGTWKSHT)\5/90 <br />