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SAN JOAOUI1e--50UNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL"R4LTH DIVISION <br /> I' LOST WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> 'NAME OF FACILITY � e SWEEPS CSE 1 C <br /> !AODRESS 11 <br /> (J TANK ID X 3 15?1 <br /> TANK SIZE `J FUEL TYPE a <br /> 11. GENERAL SITE HISTORY <br /> Is Permit current? Yes No Permit S <br /> Facility Status Code Doc.Soil/GW Coni Yes No <br /> �N�-roer of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual <br /> TANK HISTORY <br /> 'Jas Tank tested? Yes No Failed precision test 7 Yes No If yes, give daze(s) <br /> :vas 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 TPN-G TPH-0 Pb/ED8 <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= 14 10-25 <br /> ion.SiteWells) Yes Na Number 8 Type Irr Dom Pub <br /> S Score S Tndit,,n <br /> Score <br /> Distance to Wells) from Tank ft; ft; ft C 10 pts C 5 pts- <br /> 0 if 0 if <br /> R condition R condition - <br /> �V. Site Feature - Leaching Potential Analysis E is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet)0 J I4, IX )100 51-100 I 125-50\1 <br /> 'Fractures in subsurface (applies Co foothills or mountain areas) /n None Unknown I (Present <br /> Average Annual Precipitation (inches) XxXXXX <10 9 10-25 xxxXXXx 26-40\2 <br /> ,Han-Made conduits wwhich 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 K1 one one <br /> N o1— 25 cQ.9 T= 3 s 1 777 <br /> S y LUMN TOTALS>»TOTAL POINTS l O „l 7 / 3 V <br /> C -7 , Resul r. (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more v' 41 48 pts 4 O <br /> B T X I E 8 T X E <br /> MAXIMUM ALLOWABLE 8-i-%-5 LEVELS (PPM) 1 50 50 50 3 3 1. 1. NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> NC'"'3� G0 MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> DIESEL 10,000 1000 100 - <br /> FCOTNOTES: "*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 sail or ground water.) <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth <es ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for STXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). - <br /> VC_ STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 3 E or TPH Concentrations > Allowable Levels `Yes No <br /> 2. Recommend Site Closure Yesl Nol If Yes, Refer to Site Mitigation for Evaluation) <br /> Vtl. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCJR WITH STAFF RECOMMENDATION FOR CLOSURE IYES NOI REFERRED TO SITE MITIGATION FOR EVALUATION YES NOI <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />