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SAN JOAOU, 'NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL A DIVISION <br /> 1. ``/GST WORKSHEET FOR SITE CLOSURE EVALUATION DATE( <br /> NAME OF FACILITY SWEEPS CODE <br /> ADDRESS(3133 TANK10 SLV -a3 r .� 7 <br /> TANK SIZE( 3 abo1 FUEL TYPE 1 <br /> '_D1 tlls(Aygt7�js <br /> 11. GENERAL SITE HISTORY Y <br /> Is permit current?IYes x No (Permit # Facility Status Code Ooc.Soi l/GW Cont Yes Nol <br /> Number of Tanks at facility) Age of Tanks(if available) Type of Tank Steel Fbrgll Gngl 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? Yes No If yes, what was repaired?I <br /> (Was repair done under inspection? Yes No Were soil samples analyzed? Yes INo BTXEI TPH-GI (TPH-O 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 IRef/Yea r) iAverage Arcual Precipitation A= 14 10-25 <br /> On-Site WeIL(s) Yes No INumber A Type Irr Dam Pub <br /> S Scare 5 Score 5 Seore <br /> Distance to Well s) from Tank ft; ft; ft C 1D pts C 9 pts C 5 pes <br /> O 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) >100 I 51-100 I 125-50\1 <br /> ;Fractures in subsurface (applies to foothills or mountain areas) I None I Unknown Present <br /> .Average Annual Precipitation (inches) xxxxxx <10 9 110-25 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 sail, nearby wells. At least More than <br /> i xxzaxx) Alone ane one <br /> PEDI}"=.Ta}COLUMN TOTALS»>TOTAL POINTS <br /> 16)8' <br /> Sample Result: (8 T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> ) <br /> �tSI Ai3=D,,;L 5 )(,-77 8 T X E 3,1.T X E <br /> MAXIMUM ALLOWABLE 8-T-X-c LEVELS (PPM) 1 50, 50 50 .3`I.3 1. 1. NA\3 <br /> Sample Result: ' 1 dl GASOLINE 1000 100 10 <br /> I_�In ) MAXIMUM ALLOWABLE TPN LEVELS (PPM) <br /> TPH DIESEL 10,000 1000 100 <br /> 111'FOOTNOTES' :*qf documented soil and/or ground water contamination is present, thing potential <br /> PI q = lo/AFDD analysis. (i.e., site is currently an 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 8TX&E are not applicable at a TPH concentration of 10 ppn (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels I-Yes I x <br /> No <br /> 2. Recommend Site Closure Yes No •If Yes, Refer to Site Mitigation for -Eva lwaii and <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NOI IREFERRED TO SITE MITIGATION FOR EVALUATIONIYES - NO I <br /> DATE REFERRED( DATE CLOSURE LETTER MAILED <br /> NAME OF n <br /> EVALUATOR <br /> \ EH 23 80 (UGTWKSHT)\5/90 <br />