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LTH <br /> RCHMENTAL <br /> SAN JOAOU TN OT 40RKSHEETA FOR SITE CLOSUREI EVALUATIONHEt'•'' DIVISION1. DATE <br /> SWEEPS CODE <br /> NAME OF FACILITY M, <br /> TANK ID # <br /> ADDRESS � --� �5 �/�.• <br /> TANK SIZE b� FUEL TYPE <br /> II. GENERAL SITE HISTORY <br /> Is permit current? Yes No Permit No <br /> # Facy Status Code R DOc.SOiL/GW Cont Yes <br /> Number of Tanks at facility PA96f Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test 7 Yes No If yes, give date(s) <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? <br /> Was repair done under inspection? Yes No Were sail samples analyzed? Yes No BTXE TPH-G TPH•D Pb/E08 <br /> Type of failure/discharge catastrophic long-term leakage 1­rfilll 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 Ref/Year Average Annual Precipitation A= 14 10-25 <br /> On-Site Wells) Yes No Nunixr & Type Irr Dan Pub S Score S Score S Score <br /> Distance to Wells)) from Tank ft, ft; ft C 10 pts C i pts C 5 pts <br /> 0 if 0 if 0 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 /> p >100 51-100 0 25 <br /> Minimum Depth to groundwater frau the Soil Sample (teet) ,�Q J 1'aZI <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown Present-50\1 <br /> Average Annual Precipitation (inches) 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) <br /> [� At least More than <br /> Unique site features: Recharge area, coarse soil, nearby wells. xxxxxx None I one one <br /> COLUMN TOTALS»>TOTAL POINTS lo - O 3 <br /> Sample Result: (B T X OR c) RANGE OF TOTAL POINTS 49 pts or more I 41 - 48 pts 40 pts or less <br /> •s � AjJ NQ 8 T X E B T X E <br /> J MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> � R II N 7TPH <br /> DIESEL 10,000 1000 1OE- <br /> 14, <br /> 0 <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 If 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 9TX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm <br /> (diesel). <br /> 1qa `� � <br /> VI. STAFF RECOMMENDATION/CONCLUSION Sa `-'� " <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels *Yes No 1K 15 <br /> 2. Recommend Site Closure Yesl No 'If Yes, Refer to Site Mitigation for Evaluations-te S ^�/L-'� <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR J /a� �S'F�-C•'�Gj(-'J <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES ✓ NO , <br /> DATE REFERRED / Z 3 /ry JDATE CLOSURE LETTER MAILED / / <br /> NAME OF <br /> EVALUATOR ������ <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> GVd/"! �'l� <br /> /" o � o 6-Q n1 , - <br />