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SAN :OAQU(N C....-. 'ALIC HEALTH SERVICES/ENVIRONMENTAL iEALiif "1N — <br /> UCCRKSNEET FOR SITE CLOSURE EVALUATION OATS <br /> SWEEVS CODE <br /> LAME 4F FAD[L;TY i v. � �.�n e- <br /> ADDRESS O6 �Cti9�q g� TANK (D S �c 7 (mac/ <br /> TANK S:ZE! C1,5 (FUEL TYPE juj'; <br /> . GENERAL SITE HISTORY ... <br /> Is per. it current? Yes No Permit 7 - Facty it us :x: 11 zi I Doc.Soil Cont Yes No <br /> lj <br /> Nurber of Tanks at facility Age of Tanks(if available) ` Type of Tank Steel Fbrgl Sngl Dual <br /> 1. TANK HISTORY <br /> Was Tank tested? Yes NoFailed precision test 7 Yes No If yes, give date(s) <br /> was a repair made to the tank system? Yes No yes, what was repaired? <br /> was repair done under inspection? Yes No were soil saaples analysed? Yes Na BTXE TPH-G TPH-D Pb/EDB <br /> Type of failure/discharge catastrophic long-term leakage overfill unknown other: <br /> 1, REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Grourd water � Ref/Year 6 ; Average Arcual Precipitation A= 14 10-25 <br /> On-Site WeLL(s) Yes No unber & Type Irr Dom Pub S Score S Score S Score <br /> Distance to Well(s) frac Tank ft; ft; it C 10 pts G 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R coMiti on R condition R condition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> Minirt Depth to groundwater from the Soil Sample (feet) >100 51-100 25-i0\1 <br /> fractures in subsurface (applies to foothills or mountain areas) (� None Unknown Present <br /> Average Annual Precipitation (inches) <br /> 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) /v <br /> Unique site features: Recharge area, coarse soil, nearby wells. AL least More thanxxxxxxj None one one <br /> COLUMN TOTALS>>>TOTAL POINTS <br /> Sample Result: (B T % OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pis or less <br /> B T % E B T X E <br /> y <br /> MAXIMUM ALLOWABLE B-T-%-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. MA%3 <br /> Sacple Result: GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH DIESEL 10,000 1000 100 <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 1f 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 TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION 71 <br /> 1. Are BTX & E or TPN Concentrations > Allowable Levels `Yes No <br /> 2. Recommend Site closure Yes No *If Yes, Refer to Site Mitigation for Evetuation <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 YES NO <br /> GATE REFERRED / / DATE CLOSURE LETTER NAILED <br /> N HE OF <br /> EVALUATOR <br /> EH 23 110 (UGTWKSHT)\5/90 <br />