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SAN JOAOU OUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL TH DIVISION <br /> I, `i UGST WORKSHEET FOR SITE CLOSURE EVALUATIONS DATE — <br /> NAME Of FACILITY plZSWEEPS CODE a3 ! 7 <br /> ADDRESS p ,5 ;TANK 10 03 <br /> TANK SIZE 2( &�D I FUEL TYPE D i 5 QP/YI4&t<� <br /> 11. GENERAL SITE HISTORY o <br /> Is permit current? Yes No Permit 01 1- Facility Status Cade D , Doc.Soil/GW Cwt Yes <br /> Number of of Tanks at facility) Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual) <br /> III. TANK HISTORY <br /> Was Tank tested?IYes No Failed precision test ? Yes No If yes, give date(s) <br /> i <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? <br /> Was repair done under inspection? Yes Na Were soil samples anaLyted? Yes) INo BTXEI TPH-GI I TPN-0 I Pb/EDBI <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 /> Sail Samples Received Yes No Depth to Ground Water Ref/Year O(P Average Annual Precipitation A-:14 10-25 <br /> On-Site Well(s) Yes No Number 8 Type Irr Doml Pub <br /> S Score S Score S Score <br /> Distance to WeIL(s) from Tank ft; ft; ft C to 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 _ I b.=3qz3q E is met E is met E is met <br /> �Minimm Depth to groundwater from the Soil Sample (feet) >100 I51-100 I S 25-50\i <br /> i Fractures in subsurface (applies to foothills or mountain areas) V I None I Unknown Present <br /> .Average Annual Precipitation (inches) Xxxxxx <10 I 9 110-25 Ixxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> INone Unknown Present <br /> of leachate (i.e., septic systems, water welts, ponds) <br /> LUniqWa site features: Recharge area, coarse soil, nearby wells. At least More than <br /> �� a= •D,;L- X xxxxxx None ane one <br /> D6= E 113 C elb X= C M »i ;Al POINTS <br /> Sampyl/e Resuttt: (8 T X OR E7 RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> D1 <br /> 66 D,; = ap D 8 T X E 8 T X E <br /> W A.+ _! M MIDI ALLOWABLE B-T-X-E LEVELS (PPM) 1 501 50 50 .3 I3 1. 1. NA\3 <br /> �lt:� GASOLINE 1000 100 10 <br /> D D� /R TPN MAXIMUM ALLOWABLE TPH LEVELS (PPM) DIESEL 10,000 1000 100 <br /> FOOTNOTES: /y-Fpu"'If docmmmted soil and/or ground Water contamination is present, do not ere the Leaching potential <br /> A* _$i7(D /I6- analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> D r f g �� f depth is > 5 ft. and < 25 ft., scare 0 points. If depth <=5 ft., do not use table. <br /> !T(� If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> LLi L(�/• <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Fes No F S� �Lo <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 QLCJGGv 1 J <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE.YES NOI REFERRED TO SITE MITIGATION FOR EVALUATIONIYES NO <br /> DATE REFERRED. / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />