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SAN JOA©UIN 11Y#UBLIC HEALTH SERVICES/ENVIRONMENTAL HEA 0 IVISION I. UGSf WORKSHEET FOR SITE CLOSURE EVALUATION DATE 'Z NAME OF FACILITY 0_11 SWEEPS CODE ADDRESS TANK ID TANK SIZE 0 FUEL TYPE S T II. GENERAL SITE HISTOFH *** permit current? Yes No Permit # Facility Status Code Doc.SoiL/GW Cont Yes No anber of Tanks at facility Age of Tanks(if available) Type of Ta Steel Fbrgl Sng Dual 111. TANK HISTORY Was Tank tested? Yes I V1 No Failed precision test ? Yes Ref/Year No 1f yes, give date(s) On -Site Well(s) Was a repair made to the tank system? Yes No NAME OF EVALUATOR If yes, what was repaired Was repair done under inspection? Yes Dom No Pub Were soil samples analyzed? Yes No BTXE TPH-G TPH D Pb/EDB Type of failure/discharge catastrophic long term leakage overfill Score unknown Score other: IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) Soil Samples Received Yes YES I V1 No REFERRED TI SITE MITIGATION FOR EVALUATION Depth to Ground Water Ref/Year NO Average Annual Precipitation A= 14 10-25 On -Site Well(s) Yes No NAME OF EVALUATOR Number S.Type Irr Dom Pub 5 Score S Score 5 Score - Distance to WeLL(S) from Tank ft; ft; ft C 0 10 pts if C 0 9 pts if C 0 5 pts i if R condition R condition R condition V. Site Feature - Leaching Potential Analysis E is met E is met E is met Minimum Depth to groundwater from the Soil Sample (feet) >100 51-100 25-501 Fractures in subsurface (applies to foothills or mountain areas) None C l9 Unknown Present Average Annual Precipitation (inches) xxxxxx <10 10-25 xxxxxxx 26-40\2 Man -Made conduits which increase vertical migration of leachate (i.e., septic systems, water wells, ponds) None Unknown Present Unique site features: Recharge area, coarse soil, nearby wells. At least More than xxxxxx None one one COLUMN TOTALS>>>TOTAL POINTS + Sample Result: (B T X OR E) S-A..,( 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 Result: ( $ GASOLINE 1000 100 10 l -V)-pa ( « S &DD -f _TPH �) MAXIMUM ALLOWABLE TPH LEVELS (PPM) DIESEL 10,000 1000 100 FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the leaching potential analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) \1 1f depth is > 5 ft. and < 25 ft., score 0 points. 1f depth -5 ft., do not use table. \2 If precipitation is > 40 inches, score 0 points. \3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). VI. STAFF RECOMMENDATION/CONCLUSION 1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No 2. Recommend Site Closure Yes No *If Yes, Refer to Site Mitigation for Evaluation VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TI SITE MITIGATION FOR EVALUATION YES NO DATE REFERRED / / DATE CLOSURE LETTER MAILED NAME OF EVALUATOR EH 23 80 (UGTWKSHT)\5/90 �rtUS