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SAN J0AOUIN fY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE DIVISION GATE _EE <br /> I �rGST WORKSHEET FOR SITE CLOSURE EVALUATION _, <br /> p C ' S EPS CODE p�3 <br /> NAME OF FACILITY OT I\(�,�, � f <br /> tl K ID :I . <br /> ADDRESS /� J <br /> TANK SIZE _/J O (FUEL TYPE l"/o <br /> II. GENERAL SITE HISTORY <br /> Is permit current?IYes No Permit tl <br /> Facility Status Code q yjDoc.SoiL1GW Cont Yes No <br /> 3 )Age of Tanks(if available) 6�L Type of Tank Steel Fbrgl Sngl Dual <br /> Numcer of Tanks at faciLiry <br /> III. TANK HISTORY <br /> Was Tank tested?IYes �Na (Failed precision Cest ?IYes No If yes, give date(s) <br /> Was a repair made to the tank system? Yes No lif yes, what was repaired? <br /> (Was repair done under inspection?IYes INoI Were soil samples analyzed? Yes INo BTXEI ITPH-G (TPH-O Pb/ED8 <br /> !Type of failure/discharge) catastrophic Lon9"Cerm leakage overfill unknown <br /> lather: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yesl Nol Depth to Ground Water Ref/ ear , <br /> Average AnnuaL PrecipitationlA= 14 10-25 <br /> l <br /> On-Site WeIL(s) Yesl No lNnnia:r 8 TypeIrr Dom Pub <br /> ) S Score S Score S Score <br /> ft; ft; 1 C 10 pts C 9 pts CO 5fpts <br /> Distance to WeIL(s) from Tank 0 if 0 if <br /> R condition R ccndition R is motion <br /> E is met E is met "c <br /> V. Site Feature Leeching Potential Analysis l I <br /> Minimum Depth to groundwater frau the Soil Sample (feet) <br /> I >100 l I51-100 25-i0\1 <br /> Hone l I Unknown l (Present <br /> Fractures in subsurface (applies to foothnlls or mountain areas) <br /> xxxxxa <19 10-25 laxaxxxx <br /> 26-40\2 <br /> Average Annual Precipitation (inches) <br /> 0 I 1l <br /> Man-Made conduits which increase vertical migration I None I Unknown Present <br /> of leachate (i.e., septic Systems, water wells, ponds) <br /> At least More than <br /> (Unique site features: Recharge area, coarse soil, nearby wells. None one one <br /> rn <br /> l_ <br /> COLUMN TOTALS»>TOTAL POINTS <br /> Sample Re lt: (B T X OR E) <br /> RANGE OF TOTAL POINTS 49 pts or more i 41 - 43 pts I 40 pts ar Less <br /> rIIllDSPL-(J /YGncude = Co3 a T X E B T x I E <br /> " D S L- MAXIMUM ALLOWABLE 8•T-X-E LEVELS (PAM) 1 50 50 50 I .3 .3 1.� 7. NA\3 <br /> N <br /> t rPM = . GASOLINE 1000 100 10 <br /> Sf�1� Sample Result: A l <br /> UD MAXIMUM ALLOWABLE TPX LEVELS (PPM) DIESEL 10,000 1000 100 <br /> TPHTP n _ . <br /> FOOTNOTES: <br /> '**If documented soil and/or ground water contamination is present, do not complete the Leaching potential <br /> analysis. (i.e., site is currently an UGT 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 3TX&E are not applicable at a TPH calcentratfon of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION S�ipC�Kc' ✓I <br /> P1. Are BTX & E or TPX Concentrations > Allowable Levels *Yes) No �Recommend Site Closure Yesl Xo F'if Yes, Refer to Site Mitigation for 'Evaluation <br /> VII, REVIEW EVALUATION - TO BE COMPLETED SY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE(YES( IND IREFERRED i0 SITE MITIGATION FOR EVALWTIONIYES NO <br /> GATE REFERRED / DATE CLOSURE LM <br /> ETTER AILED / / <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />