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SAN JOA(IUIM` Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE`S.-bIVISION <br /> WORKSHEET FOR SITE CLOSURE EVALUATION DATE 0' <br /> NAME OF FACILITYSWEEPS CODE a I7G7 <br /> ADDRESS 34d 4pt <br /> GCcL TANK ID #13q <br /> TANK SIZE FUEL TYPE S' I I <br /> II. GENERAL SITE HISTORY <br /> is permit current? Yes No Permit # - Facility Status Code 0 � Doc.SoiL/GW Cont Yes No <br /> Number of Tanks at faciLity J Age of Tanks(if available) 3 Type of Tank Steel Fbrgl SngL Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test ? Yes Na 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 I ITPH-G TPH-0I 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 5o Ref/Year 8-6 Average Annual Precipitation A= 14 10-25 <br /> Orr Site Wells) Yes No Number 8 Type Irr Dam Pub <br /> S Score S Score S Seore <br /> Distance to WeLI(S) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pis <br /> 0 if 0 if 0 f <br /> R condition R condition R condi tion <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is nee <br /> Minin.rn Depth to groundwater from the Soil Sample (feet) 50— >100 51-100 41 25-50\1 <br /> Fractures in subsurface Capplies to foothills or mountain areas) Nate 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 ane <br /> TOIL-3 rm,+ 'e Kae— 1& 7 CAti.g"Iv aWm /a. 7$ <br /> Coq Y1Ll t✓IY1 OLUMN TOTALS»>T;JiAL POINTS + + <br /> Sample Result: (8 T X OR 'c) RANGE OF TOTAL POINTS 49 pis or more 41 - 48 pts 40 pts or Less <br /> -G X .o�AK''ki <br /> 81 T X I E 8 T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> )(_ +a* MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> T P H DIESEL 10,000 1000 100 <br /> o ate the leaching <br /> FOOTNOTES: "'If documented soil and/or ground water contamination is present, dpotential <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 STXAE are not applicable at a TPN concentration of 10 ppm_(gasoline) or 100 ,,,ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION Oh QCB15 Z,2L Q-Q, t (XyxpwQ..G-�� 1. 605) <br /> Te Stect d*J•a <br /> 1. Are 8TX 8 E or TPN Concentrations > At Lowable Levels 'Yes No <br /> hn � t e <br /> 2. Recommend Site Closure Yes No =It Yes, Refer to Site Mitigation far Evaluation •r V` I����p�. <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR O` <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES I NOI <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED / / <br /> NAME OF <br /> EVALUATOR k/\—/ <br /> EH 23 80 (UGTWKSHT)\5/90 <br />