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SAN JOAOUIITY PUBLIC HEALTH SERVICES/E4VIRONME4TAL i DIVISION <br /> 1• r/9GST WORKSHEET FOR SITE CLOSURE EVALUATION--✓ DATE _ / <br /> NAME OF FACILITY ! 4 2A2 IDi vQ�f/ti r ce5 ^✓Il (SWEEPS CODE -73 �/ I <br /> ADDRESS / �s N , H u,4 i to r Stc <br /> TANK ID .I 3 7 <br /> TANK S12E (FUEL TYPE( S / <br /> 11. GENERAL SITE HISTO6 <br /> Is permit current? Yes NOXI Pemi t C - Faci Lity Status Code I c1q <br /> DOc.SOil/GW Cant!Yes No <br /> Number of Tanks at facility Age of Tanks(if available) (Type of Tank Steel Fbrgll Sngl Dual <br /> III. TANK HISTORY <br /> Was Tank tested?IYas X INo Failed precision test ? Yes X No It yes, give dates) /A r/�' <br /> Was a repair made to the tank system? Yes No ylIf yes, what was repaired?I <br /> Was repair done under inspection?IYes INo IWere sail samples analyzed? Yell INo( BTXEI ITPH-GI ITPH-DI IPb/ED8 <br /> �IType of failure/dischargeI Icatastroph is long-term leakage overfill unknown (other. <br /> I <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 /> On-Site We(L(s)IYes NoI INumber 8 Type IIrrl IDWI Tpubl S Scare S Score S Score <br /> Distance to Wells) from Tankl ft; ft; ft C 10 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 E is met E is met "c is met <br /> Minimum Depth to groundwater from the Soil Sample <br /> (feet))—• I >100 ISI-700 I Q 125-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) I None I I Unknown (Present <br /> Average Annual Precipitation (inches) xxaxxx <10 9 110-25 Ixxxxxxxl 26-40\2 <br /> (Man-Made conduits which increase vertical migration I �\ INone Unknown Present <br /> of Leachate (i.e., septic Systems, water wells, ponds) V <br /> At Least More Chan <br /> Unique site features: Recharge area, coarse soil, nearby wells. xxxxxxl MoreQ one Qone <br /> COLUMN TOTALS»>TOTAL POINTS p?V l O I= <br /> sample Res <br /> ult: (B T X OR E) RANGE OF TOTAL 70IN75 49 pts or more I 41 - 43 pcs 40 pts or less <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 i0 50 .3 .3 11.E t. NA\3 <br /> Sample Result• <br /> 7 <br /> TP i 3b© GASOLINE 1000 100 10 <br /> PN-G ' 17 MAXIMAL ALLOWABLE TPN LEVELS (PPM) DIESEL 10,000 I 1000 <br /> N P- rJ r3V <br /> PTPx V• <br /> FOOTNOTES: --if documented sail 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 <=5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, scare 0 points. <br /> \3 Levels for STXSE are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (di eseU. <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPH Concertraii ons > AL Lovable Levels *Yes <br /> 2. Recommend Site CLosurel Yesl No •If Yes, Refer to Site Mitigation for EvaLuation 4' <br /> VII. <br /> VII. REVIEW EVALUATION - TO BE CCMPLETED BY A SUPERVISOR/SENIOR <br /> IYES NOI (REFERRED TO SITE MITIGATION FOR EVALWTIONYESI INOI <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE <br /> GATE REFERRED / DATE CLOSURE LETTER MAILED <br /> / 2 `J <br /> NAME OF - <br /> EVALUATORI <br /> EH 23 30 (UGTWKSHT)\5/90 <br />