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LTH <br /> RONMENTAL <br /> SAN JOAOULN COUNT UORKSHEETAFOR SITE CLOSURE EVVALUATIONHEALTH DIVISION DATE <br /> NAME OF FACILITY G WEEPS CODE v 7 7 <br /> ADDRESS I q S 61 W�(tel � S� TANK ID # / - -�� <br /> TANK SIZE 00 Z FUEL TYPE <br /> 11. GENERAL SITE HISTORY yam+ <br /> Is permit current? Yes No Permit # - Facil Lty Status Code Doc.Soil/GW Cont Yes No <br /> Number of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl SngL Dual <br /> Ill. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test ? Yes No If 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 No were soil samples analyzed? Yes No BTXE TPH-G TPH-D IPb/E <br /> Type of tai lure/discharge catastrophic long-term leakage overfill unknown other: <br /> 1V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COL ECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Ground water Ref/Year I�; <br /> Average Annual Precipitation A= 14 10-25 <br /> on-Site Welts) Yes No Number & Type Irr Dom Pub <br /> S Score S Score 5 Score <br /> Distance to WeLL(s) from Tank ft; ft; ft C 10 pts C i pts C i pts <br /> 0 if o if 0 if <br /> R condition R condition R condition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> Minima Depth to groundwater from the Soil Sample (feet) <br /> >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) <br /> d None Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration None 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. %Xx)U(X None one one <br /> COLUMN TOTALS»>TOTAL POINTS <br /> Sample Result: IS T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> B T X E B T X E <br /> Q MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 <br /> Sample Result: <br /> GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) 100 <br /> T FAI DIESEL 10,000 1000 <br /> FOOTNOTES: `•'If documented soil 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 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 BTX&E are not applicable at a TPH concentration of 10 ppa (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPN Concentrations > Allo able Levels *Yes No <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 <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES \NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE.REFERRED / �J / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR / <br /> EH 23 80 (UGTWKSHT)\5/90 <br />