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SAN JOAOUTAk, ,.CY PUBLIC HEALTH SERVICES/ENVIRONMENTAL Hem/ OIVISION I J <br /> I_ UGST WORKSHEET FOR SITE CLOSURE EVALUATION GATE 79 <br /> NAME OF fACILtTY I C�Lr D N rti C I� rGC �� S IE_oS COOEI <br /> ADOREss 31 `J'7 S r " �(}'j�( TANK LD sIg <br /> -- O <br /> TANK SIZE 1 DDDS FUEL TYPE D i <br /> 11. GENERAL SITE HISTORY <br /> Is Permit current? Yes No Permit 91 1- Facility Status Code Q / Doc.Soi L/GW catt Yea No <br /> Number of Tanks at facility Age of Tanks(if available) � i�IType of rank Isteel IFbrgLl Sm I. Duo/ <br /> III. TANK HISTORY L.:.'" .3 3Q (TKadt <br /> Was Tank tested? YesNo (Failed precision test ?(Yes No If yes, give dates) 013/ / d; <br /> Was a repair made to the tank system?IYes i mol IIf yes, what was repaired? 4'- vat p <br /> Was repair done under inspection? Yes No Were soil samples analyzed? YeaI NoITTXE ITPM-G TPH-0 P6/EDB <br /> Type of failure/discharge catastrophic Itom-term Leakage Ioverfilt Iunknown lother: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Sail Samples Received Yes No (Depth to Ground Water Ref/Year (Average Amual PrecipitationIA= 14 10-25 <br /> On-Site Wells) Yes No Number d Type Irr Dan IPual <br /> S Score S Score S Score <br /> Distance to Welts) from Tank ft; ft; ft C 10 pis C 9 pts C 5 pts <br /> O if 0 if 0 if <br /> R condition R condition R condition <br /> V. Site Feature - Leaching Potential Analysis E is met -c is met E is met <br /> Minimum Depth to groundwater from the SoiL Sample (feet) _ I -100 I I51-100 I 125-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) I None Unknown (Present <br /> Average Annuat Precipitation (inches) xxxxxxl <10 I 9 10-25 Ixxxxxxxj 25-40\2 '. <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) None I Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. I At least More than <br /> )O=xx Rine one one <br /> COLND) TOTALS»>TOTAL POINTS <br /> Sample Result: B T X OR E) RANGE OF TOTAL POINTS 49 pts or more I 41 - 4d pts 40 pts or Less <br /> o� s�� <br /> BT X E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS CPPM) 1 So SOI 50 .3 .3 1. 1. RA\3 <br /> Sample Result: AL t7: GASOLINE 1000 100 10 <br /> -1 D6O MAXIMALLOWABLE TPN LEVELS CPPM) <br /> •�p( � LL's\�TPHD DIESEL 10,000 1000 100 <br /> FOOTNOTES: * if documented wit and/or ground water commination is present, do not complete the leaching potettiat <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or grand water.) <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth =5 ft., do rot use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for STXdE are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No <br /> 2. Recommend Site Closure Yes No If Yes, Refer to Site Mitigation for =_vatuationl <br /> VII. REVIEW EVALUATION - TO BE COMPLETED SY A SUPERVISOR/SENIOR <br /> CCNCUR WITH STAFF RECOMMENDATION FOR CLOSURE YESJ NOI IREFERRED TO SITE MITIGATICN FCR =VALUATION YESI INOI <br /> DATE REFERRED / / DATE CLOSURE LETTER RAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />