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SAN JWOUIN COINTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEO'TH DIVISION 1. 'T WORKSHEET FOR SITE CLOSURE EVALUATION DATE /Z NAME OF FACILITY �p.(=.�� sv1/.-� r SG SWEEPS CCOC/ ADDRESS TANK ID a b yT O� OZ TANK SIZE 5(i0 ,$7id FUEL TYPE G�.S �- �P�/ 9 f3 -2 11. GENERAL SITE HISTORY Is permit current? Yes No No Failed precision test T Permit C - Facility Status Code k If Doc.Soil/GW Coni Yes No Yes Number of Tanks at facility Was repair done hander impaction? Age of Tanks(if available) Type of Tank Steel Were soil simples aro lyzed? Fbrgl Sngl Dust BTXE tit. TANK HISTORY Was Tank tested? Yes ,% No REFERRED TO SITE NITI WTIOM FOR EVALUATION Failed precision test T Yes No k If yes, give date(s) / Was a repair made to the tank system? Yes No Number If yes, what was repaired? Was repair done hander impaction? Yes No Were soil simples aro lyzed? Yes No BTXE TPN -G TPH-D Pb/EDB Type of failure/discharge catastrophic lung -term leakage overfill I i unknown I other: IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) Soil Samples Received Yes ,% No REFERRED TO SITE NITI WTIOM FOR EVALUATION Depth to Ground Water Ref/Year Average Annual Precipitation As 14 10-25 On -Site WeLL(s) Yes No Number L Type Irr Dam Pub S C Score 10 pts S C Score 9 pts S C Score 5 pis Distance to WeLL(s) from Tank ft; ft; ft 0 R E if condition is met 0 R E if condition is Rat 0 R E if condition is met V. Site Feature - Leaching Potential Aro lysis Minimum Depth to groundwater from the Soil Sample (feet) >100 51-100 25-50\1 i Fractures in subsurface (applies to foothills or mountain areas) Nonwe Unkrwhan Present Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxy= 26-40\2 Man -Made conduits which increase vertical migration of leachate (i.e., septic systems, water wells, ponds) Nora Unknown Dresmt Unique site features: lafharge area Cars soil arby Wells. l At least More than . ,. y- xxxxxx None one one 0 POINTS I� TALI TOT Semple Result: (6'T X O�jR�yEE)Y✓` IPPV" I RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 Sample ResulGASOLINE 1000 100 10 MAXIMUM ALLOWABLE TPN LEVELS (PPM) N DIESEL 10,000 1000 100 DOTTE$:_ documented soil and/or ground water contamination is present, do not complete the leaching potential ,Qyf" ..�'Y" analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) IV L P" t depth is > 5 ft. and < 25 ft., score 0 points. !f depth <-5 ft., do not use table. / f precipitation is > 40 inches, score 0 points. f�✓ Levels for BTXZE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). VT. STAFF RECO141ENDATION/CONCLUSION 1. Are BTX 8 E or TPH Concentration > Allowable Levels 'Yes ='-No 2. Recooaend Site Closure Yes No if Yes, Refer to Site Mitigation for Evaluat VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE TES ,% NO REFERRED TO SITE NITI WTIOM FOR EVALUATION YES NO DATE REFERRED / / DATE CLOSURE LETTER MAILED / / NAME OF E`IALUATOR f EH 23 80 (UGTWKSHT)\5/90 /