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SAH JOAQUIN COUh�BLIC HEALTH SERVICES/ENVIRONMENTAL HEALTF '1SION DATE( <br /> UG RKSHEET FOR SITE CLOSURE EVALUATION <br /> I- <br /> s SPIEEPS CODE Q(�/3 <br /> NAMi OF FACILITY <br /> �� TANK 10 A 9F' <br /> ADDRESS f <br /> FUEL TYPE <br /> TANK SIZE 1 L <br /> II, GERERAL SITE HISTORY <br /> Is permit current? Yes No Permit # fFaciLity Status Code Ooc.Soii/GW Cont Yes No <br /> N�,oer of Tanks at facility <br /> 7 Age of Tanks(if available)( Type of Tank Steel Fbrgl Srvgt Dual <br /> III. TANK HISTORY <br /> } give date(s) <br /> Was Tank tested? Yes No i FaiLed precision test ? Yes INa If yes, <br /> was a repair made to the tank system? Yes No If yes, what was repaired?� <br /> Was. repair done under inspection? les No were soil samples analyzed? Yes Na` BTXE TPH-G (TPH-DI IPbJEDBI <br /> Type of failure/discharge catastrophic Long-term Leakage werfilL unknown) other. <br /> IV. REMOVAL HISTCRY (ATTACH INSPECTION REPORT FCR SITE DETAILSICOLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Sail "samples ReceivediYes Ha� (Depth to Ground water Ref/Year ; <br /> (Average Annual Precipitation A= 14 �10-25 <br /> On-Site ueLl(s)IYes �No Number 3 Type Irr Dam Pub S Scare S Score S Scare <br /> ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> Distance to welt(s) from Tank 0 if 0 if 0 if <br /> R condition R condition R condition <br /> V. site Feature - Leaching Potential Anatysis <br /> C 15 mel C 1S met i5 met <br /> �/� <br /> >100 I51-400 ` ZS-58\1 <br /> Minimum Depth to groundwater from the Soil samo(e (feet) 46— <br /> Fractures in subsurface (applies to foothills or ountain areas) <br /> None I Unknown I Present <br /> <10 4 10-Z5 Ixxxxxxxl 26-48\2 <br /> Average Annual Precipitation (inches) <br /> I <br /> Man-Made conduits which increase vertical migration Dane I I Unknown Present <br /> of leachate (i.e., septic systems, water welts, ponds) <br /> { � At least More than <br /> Unique site features: Recharge area, coarse sail, nearby wells- x,=x� None II one <br /> COLUMN TOTALS»>TOTAL POINTS <br /> } <br /> sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more I 41 - 48 pts I 48 5tess <br /> tip� ; vr> ( Dp3.-� ..�t� <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) B 50 50� 50 .3 .3 1.1 1. �, ' <br /> GASOLINE 5000 I 100 � �Sample Result: �� MAXIMUM ALLOWABLE TPH LEVELS (FPM) 1000 TPHD[ESEL 10,000 <br /> do not complete theFOOTNOTES• **"If docmented soil and/or ground water contamination is present, water. <br /> analysis, (i-e. site is currently on UGT Contamination List for soil or ground <br /> \1 If depth is > 5 ft- and < 25 ft., score 0 paints. If depth ci ft., do not use table_ <br /> 7 fU \2 If precipitation is > 40 inches, score 0 points. <br /> �\3 Levels for 3TX&E are not applicable at a TPH concentration of 10 ppm (gasoLine) or 100 ppm (diesel). <br /> VT. STAFF RECCMMENDATION/CONCLUSION <br /> 1. Are 3TX & E or TPH Concentrations > ALLowable Levels *YesA INo v� <br /> 2. Recommend Site Closure Yes INo *If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO 3E Ct241PLETED SY A ERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATIONFOR CLOSURE YES` INOI REFERRED TO SITE MITIGATION FOR -EVALUATION YES IND <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/40 <br />