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SAN JOAOUTT WTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H .''DIVISION p' <br /> 1, w�JGST WORKSHEET FOR SITE CLOSURE EVALUATION .... DATEI O'Q 1 g <br /> NAME OF FACILITY , 6 S (SWEEPS CODE a 3 , b <br /> ADDRESS I 0 .5 Sra T) TANK ID X - /© '5� <br /> TANK SIZE I FUEL TYPE Z)ly <br /> II. GENERAL SITE HISTORY <br /> Is permit current? YesNo Permit w< - Facility Status Cade Q / Doc.SoiL/GW Cont Yes lNold <br /> Number of Tanks at facility Age of Tanks(if available) /� IType of TanklSteel Fbrgl SngLI Oual <br /> III. TANK HISTORY '#1 <br /> Was Tank tested? Yes No Failed precision test ?I Yes Na If yes, give date(s) <br /> Was a repair made to the tank system? Yes No IIf yes, what was repaired? <br /> Was repair done under inspection? Yes No Were soil samples analyzed? yesl INoI STXE ITPH-G TPH-O Pb/EDB <br /> Type of failure/discharge catastrophic hong-tern Leakage overfill unknownI Iother: <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 Precipitatiwj Aa 11. 10-25 <br /> an-site Welt(s) Yes No Number 8 Type Irrl Dam Publ <br /> S Score S Scare S Score <br /> Distance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if O if 0 if <br /> R condition R condition R condition <br /> V. Site Feature - Leaching Potential Analysis E is met = is met E is met <br /> Minimum Depth to groundwater from the Sail Sample (feet)_35-15rvdb >100 I I51-100 I © 125-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) / 0 None I Unknown (Present <br /> Average Annual Precipitation (inches) m=xX 00 I 9 i 10-25 I:OnN)DnXul 26-40\2 <br /> i <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water welts, ponds) / 0 None Unknown (Present. <br /> Unique site features: Recharge area, =arse soil, nearby wells. At least) More than <br /> XXKXXX Nene one One <br /> COLUMN TOTAL9»TOTAL POINTS 0 « I « <br /> Sample Result: (S T XX OR E) RANGE OF TOTAL POINTS 49 pts or more I 41 - 4a pts 40 pts or Less <br /> K I F.. �_1 ;0'I JL B T X E g T X <br /> J/1� <br /> MAXIMUM ALLOWABLE 3- <br /> Sample <br /> LEVELS (PPM) 1 50 50I 50 .3 .3 11. 1 NA\3 <br /> Sample Result: ' GASOLINE 1000 100 10 <br /> 1 K I '_1*000.p IMAd ALLOWABLE TPN LEVELS (PPM) <br /> DIESEL 10,000 1000 100 <br /> FOOTNOTES: " If documented soil and/or ground water contamination is present, do not complete the leaching po taL <br /> analysis. (i.e., site is currently an UST 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 aTXSE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel)A e •�/7��' <br /> V1. STAFF RECOMMENDATION/CONCLUSION — / <br /> �fOG��7f lei s w� >n <br /> 1. Are RTX 8 E or TPN Concentrations > Allowable Levels 'Yes No <br /> !T V Alq� <br /> 2. Recommend Site Closure Yes No If Yes, Refer to Site Mitigation for Evaluation %�CQ <br /> VII. REVIEW EVALUATION - TO BE CCMPI.E7ED aT A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YESI NOI (REFERRED TO SITE MITIGATION FOR eVALUATTON YES( INOI <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED F / / <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 3 P3 + q- �E/�(, ,, Q Y8 <br /> �LCY///lla /l i /RI:.. <br />