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SAN JOAQUINTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE DIVISION <br /> ` <br /> I !GST WORKSHEET FOR SITE CLOSURE EVALUATION �� DATE <br /> NAME OF FACILITY . WEEPS CODE , 3 <br /> i <br /> ADDRESS TANK ID <br /> �� ) <br /> TANK SI2E <br /> 1I. GENERAL SITE HISTORY /J ••• <br /> Is permit current? Yes INo (Permit # - Facility Status Lade Ooc.Soi l/GW ContYes No <br /> Numcer o£ Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual <br /> III. TANK HISTORY <br /> Was Tank tested. Yes IHo (Failed precision test ? Yes No lif yes, give date(s) / <br /> Was a repair made to the tank system? Yes No if yes, what was repaired? <br /> Was repair done under inspection?(Yes INo( Were soil samples analyzed? Yes No BTXE (TPH-GI iPH-0 Pb/EDB <br /> Type o£ failure/discharge) catastrophic Long-term leakage overfill unknown (other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILSJfAILECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yesl INo( <br /> Depth to Ground Water Ref/Year , <br /> Average Annual Precipitation)A= 14 10-25 <br /> (On-site WeLI(s)IYes Nol (Number & Type lrr Doml Pub S Score S Score S tank Score <br /> O istance to Wells) tram ft; ft; ft C 70 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 <br /> E is met E is met _ is met <br /> Minimum Depth to groundwater tram the Sail Sample (feet) <br /> >100 1 151-100 125-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) <br /> 1 None Unknown Present <br /> 1 I ( <br /> Average Annual Precipitation (inches) <br /> xi,.F710 9 10-25 xXxxxxxl 26-40\2 <br /> Man-Made conduits which increase vertical migration I None Unknown Present <br /> of leachate (i.e., septic systen8, water wells, Ponds) <br /> At Least) More than <br /> (Unique site features: Recharge area, coarse soil, nearby wells. xxxxxx Nona we one <br /> + I + I= <br /> COLUMN TOT LS »TOTAL POINTS <br /> Sample Res C: IS T % OR E RANGE OF TOTAL POINTS 49 pts or more I 41 - 48 pis I 40 pts or less <br /> ) ll1�_(�, L�Q(� <br /> � I Yr=0.01Y B T X E a T X I E <br /> of ' o•0''I MAXIMLUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> _ GASOLINE 1000 100 10 <br /> amp a Respy��i 17Pk " �' � TPF( MO = 7•�i <br /> 1�l ;q,O•(.( 1/'a IMUM LOWABLE TPM LEVELS (PPM) DIESEL 10,000 1000 I 100 <br /> FOOTNOTES: <br /> ..If documented soil and/or ground water contamination is present, do not cowLete 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 BTXBE are rot applicable at a TPH concentration of la ppm•(gasoline) or 100 ppa (dies�e-l).�/�7�/J�� <br /> VI. STAFF RECOMMENDATION/CONCLUSION (, TP If 61- <br /> PH <br /> ? I <br /> Fl.: Are BTX S E or TPH Concentrations > Allowable Levels 'Yes No Recommend Site Closure Yesl INo •If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED 0 A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSUREIYESI IN (REFERRED TO SITE MITIGATION FOR EVALUATIONIYESI NOI <br /> / DATE CLOSURE LETTER MAILED( J J <br /> DATE REFERRED / <br /> NAME OF <br /> EVALUATOR <br /> EN 23 30 (UGTWKSHT)\5/90 <br />