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SAN NAME OF FACILITY ��I JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTw DIVISION WORKSHEET FOR SITE CLOSURE EVALUATION �� Y r SVE-EPS CODE YES No DATE Failed precision test 7 Tea Ref/Year ADDRESS ll () P"rI VZ 14 TANK ID 0 Yes - 0Z I TANK SIZEI l (FUEL TYPE V . IL GENERAL SITE HISTORY v tt Is permit current? Yes No Permit Y N 'q' Facility Status Code Docof GW C No Number of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual III. TANK HISTORY Was Tank tested? Yes YES No NO Failed precision test 7 Tea Ref/Year No if yes, give date(s) 14 Was a repair made to the tank system? Yes No NAME JF If yes, what was repaired? Was repair done under inspection? Yes No Were soil staples analyzed? Yes Pub No BTXE TPH-GJ TPH-D Pb/EDB Type of failure/discharge catastrophic tong -tem Leakage overfill unknown other: IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) Soil Samples Received Yes YES No NO Depth to Ground Water YESI NO Ref/Year Average Annual Precipitation A• 14 10-25 Cn-Site WeMs) Yes NAME JF No Number L Type Irr Om Pub 5 C Score 10 pts S C Score 9 pts 5 C Score 5 pts Distance to WeLL(s) frac Tank ft; ft; ft 0 R if condition 0 R if condition 0 R if condition V. Site Feature . Leaching Potential Analysis E is met E is .ret E is met Minimm Depth to groundwater from the Soil Sarrple (feet) >100 51-100 25-50\1 Fractures in subsurface (applies to foothills or mxxNltain areas) None Unknown Present Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 Man -Made conduits which increase vertical migration of leachate (i.e., septic systems, water wells, ponds) None Unknown Present Unique site features: Recharge area, coarse soil, nearby wells. At least More than xxxxxx None one one COLUMN TOTALS>>>TOTAL POINTS I t Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 48 pts 40 pts or less BT X E B T X E MAXIMUM ALLOWABLE B -T -%-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 SaiTLe Result: GASOLINE1 1000 100 10 MAXIMUM ALLOWABLE TPN LEVELS (PPM) TPH DIESEL 10,000 1000 100 FOOTNOTES: —If documented soil ad/or grand water contamination is present, do not ccaplete chs Leaching potential analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) \1 If depth is > 5 ft. and < 25 ft., score 0 points. if depth «5 ft., do not use table. \2 If precipitation is > 40 inches, score 0 points. \3 Levels for STX8E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). VI. STAFF RECOMMENDATION/CONCLUSION 46 y- u,Hu,172X&2) 1. Are BT% 3 E or TPN Coentratia> A wabl s 'Tem Na IS �-0-1 l&�t'yLL/�j rcro fYam 46Vn K 4- I rom, cva-.Q . 2. Recomend Site Closure Yes No 'If Tea, Refer to Site Mitigation for Evaluation VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR CCNCJR WITH STAFF RECOMMENDATION FCR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YESI NO DATE REFERRED / / DATE CLOSURE LETTER MAILED / / NAME JF EVALUATOR EH 23 30 (UGTWKSHT)\5/90