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SAN JOADUINi'qMOTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE,.,iA DIVISION <br /> 1, UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE 7—,-2— 7C? <br /> NAME OF FACILITY / �' - SWEEPS CODE q316-1* <br /> ADDRESS 3 / 3 / 'f®c- ­l-e,� I TANK ID # ' <br /> TANK SIZE 600 FUEL TYPE ` 64or ©f <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? Yes No Permit # - Facility Status Code 0C.Soit/GW Coni Yes No <br /> Number of Tanks at facility �-�-- Age of Tanks(if available) /J Type of Tank Steel Fbrgl Sngl Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test ? Yes No If yes, give dates) <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? TA111T �� �`(�'yYl�(11•/`,< O <br /> Was repair done under inspection? Yes No Were soil samples analyzed? Yes No BTXE TPH-G TPH-D 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 Ref/Year Average Annual Precipitation A=114 10-25 <br /> On-Site Well(s) Yes No Number & Type Irr Dam Pub <br /> S Score 5 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 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) 50 >100 51-100 41 25-50\1 <br /> Fractures in subsurface (applies to foothiLLs or mountain areas) More 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 systema, water weLLs, ponds) more Unknown Present <br /> Unique site features: Recharge area, coarse soiL, nearby wells. At least More than <br /> xxxxxx Mane one one <br /> COLUMN TOTALS>>>TOTAL POINTS ' ' <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or Less <br /> B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> TPH FDI E S E LMAX IMIM ALLOWABLE TPH LEVELS (PPM) <br /> 10,000 1000 100 <br /> FOOTNOTES: ***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 BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION k)070 - P. n <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No 7 /\1•T /G 5o(� <br /> 2. Recommend Site Closure Yes No If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />