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SAN 10ACUIHPUBLIC HEALTH sEaviC_S/EHVIROHMENTAL HF-AE I.IVISION <br /> I. � WORKSHEET FOR SITE CLOSURE EVALUATION BATE <br /> NAME OF FACILITY ( Sul <br /> ESPS COBE �O <br /> ADDRESS C9�S 1 TANK 10 A - <br /> TANK SIZE FUEL TYPE <br /> II. GENERAL SITE HISTORY — J Q /) (/ <br /> Is permit current? Yes INo Permit - IFacility Status Code Doc.Soit/GN Cont Yes No <br /> Humber of Tanks at facitityl Age of Tanks(if available) (Type of Tank Steel rbrgLI lSngLlDual <br /> III. TANK HISTORY <br /> Was Tank tested? YesHo Failed precision test ? Yee NoI If yes, give date(s) <br /> was a repair made to the tank system! Yes NaI If yes, what was repaired?I <br /> Was repair done under inspection?I Yes NoI Were soil sam pies analyzed? Yes No BTXE TPH-G ITPH-D IPb/EDB <br /> Type of failure/discharge (catastrophic long-term leakage loverfiLt Iunknaun other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FCR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes no Depth to Ground Water Ref/Year Average Annual Precipitation An 14 10.25 <br /> On-Site Welt(s) Yesl No (Number & Type Ilrr Dom Ipub <br /> � S Scare S Score S Score <br /> (Distance to WetL(S) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> a if a if 0 if <br /> R condition R condition R condition <br /> V. Site Feature - Leaching Potential Analysis c is met E its met E is met <br /> (Minimum Depth to groundwater from the SoiL Sample (feet) so I >100 II51-100 <br /> Fractures in subsurface (applies to foothills or mountain areas) 1� I None I Unknown I (Present <br /> Average Annual Precipitation (inches) xxxxxxl (10 I 9 110-25 Ixxxxxxxa 26-4012 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) Hone Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby weiis. I At Least f more than <br /> xxxxxx None oneil f! one <br /> COLUMN TOTALS)>>TOTAL POINTS C I + �� * I— �f <br /> Sample Result: (S T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts ( 40 pts or Less <br /> r ��-3 �,01 s Tlxf E B .3TIx E <br /> MAXIMUM ALLOWABLE 3-T-K-E LEVELS (PPM) 1 501 50 50 .3 1. 1. NA 13 <br /> Sample Result:,- �j p{1 M GASOLINE 1000 100 I 10 <br /> p 1181 Cn ?(IMUM ALLOWABLE TPH LEVELS (AAM) <br /> !I r DIESEL 10,000 I 1000 I 100 <br /> FOOTNOTES: *" Tf documented soil and/or ground crater contamination is present, do not complete the Leaching potential <br /> analysis. (i.e., site is currently an (IGT Contamination List for sait or ground water.) <br /> 11 If depth is > 5 ft. and < 25 ft., scare a points. If depth <=9 ft., do not use table. <br /> 12 If precipitation is > 40 inches, score 0 points. <br /> 13 Levels for STX&E are not applicabie at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel), <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > ALLowable Levets *Yesl No ✓ Cx1 "� l ji <br /> 7 / -AIP <br /> 2. Recommend Site CtosurelYesl No �If Yes, Refer to Site Mitigation for rvatuation <br /> VII. REVIEW EVALUATION - TO SE CO14PLETEO BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YE HOI REFE.4RED TO SITE MITIGA ON FCR EVALLIATIOHIYES INQI I <br /> GATE REFERRED( / / (DATE CLOSURE LETTER MAILS <br /> HAKE OF <br /> EVALUATOR <br /> EN 23 80 (UGTUKSHT)15/90 �: <br />