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Y PUBLIC <br /> ALTH <br /> RONMENTAL <br /> SAN lOAOU1N C%,5 <br /> ST WORKSHEETA FOR SITE CLOSURE I EVALUATION HEA(�)IVISION DATE( 'a_i3�G <br /> I. <br /> INAME OF FACILITY IN� ,• u'N (SWEEPS COOEI <br /> ADDRESS I W\I t� ��1 (�/� a TANK ID #I <br /> TANK SIZE( +VIDyIFUEL TYPEdIeSd <br /> 11. GENERAL SITE HISTORY *+* <br /> Is permit current? Yes No (Permit # - Facility Status Cade Da0.Sa1 L/GW Cont�Yes No <br /> Numoer of Tanks at facility 2 (Age of Tanks(if available) �ylf[„ Type of T Steel Fbrgl sngl Dual <br /> III. TANK HISTORY <br /> Was Tank tested? !No (Failed precision test ?(Yes No If yes, give date(s) <br /> Was a repair made to the :ank system? Yes No If yes, what was repaired'? <br /> Yes INo (Were sail samples analyzed? Yes Nol BTX E (TPH-GI ImPH-O Pb/ED8 <br /> �IWas repair done under inspection?( <br /> i <br /> ITYpe 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 l7 es No Depth to Ground Water Ha (Rei/Year 0 ; <br /> Average Annual Precipitation)A= 14 10-25 <br /> On-Site Well(s)I Yesl NoI INinkxr i Type Irr Dotal Pub) S Score S Score S Score <br /> Distance to WeIL(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if O if 0 i4 <br /> R condition R condiiian R condition <br /> V. Site Feature - Leaching Potential Analysis <br /> E is met 'e is pec _ is met <br /> Minimum Depth to groundwater from the Soil Sample (feet) <br /> I >100 I51-100 I 25-50\1 <br /> None Unknown Present <br /> Fractures in subsurface (applies to foothills or mountain areas) <br /> I I ( <br /> <W 9 110-25 Ixxxxxxxj 26-40\2 <br /> (Average Annual Precipitation (inches) <br /> Man-Made conduits which increase vertical migration None I Unknown Present <br /> of Leachate (i.e., septic system, water wells, ponds) <br /> At least Wore than <br /> (Unique site features: Recharge area, coarse soil, nearby wells. XXXXXX More one one <br /> I_ <br /> COLUMN TOTALS>>>TOTAL POINTS <br /> Sample Result- (8 T X OR E) RANGE OF TOTAL POINTS 49 pts or more I 41 - 4B pts I 40 pts or Less I <br /> B T X E 7 X I E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 I -.31 -3 1.1 1. NA\3 <br /> Sample Result: <br /> GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) 100 <br /> TPH [DIESEL 10,000 I 1000 <br /> FOOTNOTES: <br /> —"if documented soil and/or ground water contamination is present, do not complete the 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 (dies eL), <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 3 E or TPH Concentrations > Allowable Levels *Yell INo <br /> 2. Recommend Site CLosurelYesl INo •If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BT A surEM SOR/SENIOR <br /> CONCUR WITH STAFF RECCMMENDATION FOR CLOSURE IVES INO IREFERRED TO SITE MITIGATION FOR EVALUATIONIYEs NCI I <br /> / DATE CLOSURE LETTER MAILEDI <br /> DATE REFERRED( / <br /> NAME OF <br /> EVALUATCRI <br /> EH 23 30 (UG7WKSHT)\5/90 <br />