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SAN d0A0UI" INTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL TH DIVISION <br /> I. �JGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE ///L r6, <br /> NAME OF FACILITY �) / Siz _ToF SWEEPS CODE <br /> ADDRESSjz/r F7 _rWAl TANK ID/X sn - <br /> TANK SIZE .63;Z, FUEL TYPE <br /> It. GENERAL SITE HISTORY <br /> Is permit current? Yes No Permit N - Facility Status Code Doc.Sail/GW Cant Yes <br /> all <br /> Number of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test ? Yes N,7 If yes, give date(s) <br /> Was a repair made to the tank system? Yes Na If yes, what was repaired?I <br /> Was repair done under inspection? Yes No IWere sail samples analyzed? Yes No BTXE TPH-G TPH-01 Pb/EDB <br /> Type of failure/discharge catastrophic long-term Leakage overfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Ground Water y5 Ref/Year F6i Average Annual Precipitation)A= 14 10-25 <br /> On-Site Wells) Yes No Number & Type Irr Dam Pub <br /> S Score 5 Score S Score <br /> Distance to WeIL(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> O if O if O 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 /> IMinimum Depth to groundwater from the Sail Sample (feet) f,�o >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None I Unknown (Present <br /> (Average Annual Precipitation (inches) xxxxxxl <10 9 10-25 Ixxxxxxxl 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) j D None Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> xxxxxx None a ane one <br /> COLUMN TOTALS>>>TOTAL POINTS <br /> Sampt Result: (S T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 -_48 pt 40 pts or less <br /> 7.3=N.0/.:�l/�i4E-..I.D.; .cwS/iP`• ___ <br /> wa`+H 9 T X E B T X E <br /> K_,{.A'; •�>PV'' MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> 'Sample ReSULr:_ GASOLINE 1000 100 10 <br /> al•i'. , -,V't, V11 D MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> rJ.n.', io ,„'• -- TPH-io, DIESEL 10,000 1000 I 100 <br /> FOOTNOTES: "'•If documented soil and/or ground water contamination is present, do not complete the Leeching 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., scare 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 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels "Yes Na <br /> 2. Recommend Site Closure IYes l '? No I �•(f Yes, Refer to Site iHit <br /> igation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES O REFERRED TO SITE MITIGATION FOR EVALUATION YES IN <br /> DATE REFERRED IDATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />