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SAN JOAOLAwftOUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL' "LTH DIVISION <br /> 1. LOST WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> !NAME OF FACILITY <br /> SWEEPS CODE <br /> 'ADDRESS S' <br /> TANK S11 fil FUEL TYPE �y <br /> II- GENERAL SITE HISTORY /�T�/Q <br /> ..* <br /> Is permit current? Yes No Pennii ! - Facility Status Code Doc.Soil/GW Cont Yes No <br /> �Mumer of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl Snal D t <br /> ... TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test 7 Yes No If yes, give date(s) <br /> ':as 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 INo BTXE TPN-G TPH-0 Pb/EDB <br /> ;Type of failure/discharge catastrophic long-term Leakage) overfill unknown other: <br /> 1V. 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= 74 10-ZS <br /> 'On-Site Wells) Yes No Number & Type Irr Dan Pub <br /> S Score S TScoreSScore <br /> !Distance to Wells) from Tank ft; ft; ft C 10 pts C 5 pis <br /> 0 if 0 if <br /> R condition R condition <br /> 'V. Site Feature - Leaching Potential Analysis E is mer E is met <br /> Minimun Depth to groundwater from the Soil Sample (feet) Iyf� — ((y s 01� >100 51-100 25-50\1 <br /> (Fractures in subsurface (applies to foothills or mountain areas) 10 None Unknown I 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) 1 v None Unknown Present <br /> (Unique site features: Recharge area, coarse soil, nearby weLLs. At Least More than <br /> xxxxxx None one one <br /> � COLUMN TOTALS»>TOTAL POINTS <br /> O I <br /> !Samole Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 0 40 pts or Less <br /> Al= All (U D <br /> a /(f l( (L)DB T X E B 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 /> N N MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH DIESEL 10,000 1000 100 <br /> F•COTNOTES: "**If documented soil and/or ground water contamination is present, do not complete the Leaching potential <br /> 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 BTX&E are not applicable at a TPH concentration of 10 ppm (gaso(ine) or 100 ppm Cdiesel). <br /> V1. STAFF RECOMMENDAT i ON/CONCLUSION U C' n O , <br /> 1. Are 8TX & E or TPM Concentrations > At lllowable Levels *Yes) No Gr, <br /> 2. Recommend Site Ctosure YesXl No *If Yes, Refer to Site Mitigation for Eva(UC _ <br /> ua ron <br /> '/ FccQc� G <br /> VII. REVIEW EVALUATION - i0 BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSUREIYES NOI 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 />