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#'WORKSHEET SAN JOAUU14 COPUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL ;'iSION FOR SITE CLOSURE EVALUATION DATE ..AME OF FACILITY V SWEEPS CODE ADDRESS AN C.� FV I ,n /) TANK ID # _ TANK S12E r.F 00 C) FUEL TYPE 1%-1 / Oil 11. GENERAL SITE HISTORY t V9 a** > permit current? Yes ✓ No Permit # Vh (3 �31 LK�I Facility Status Code Doc.Soil/GW Cont Yes No Anber of Tanks at facility `y Age of Tanks(if available) Type of Tank Steel A Fbrgl SngL Dual Was Tank tested? Yes ✓ No Failed precision test o Yes Ref/Year No Average Annual Precipitation A= 14 Was a repair made to the tank system? Yes No 1% If yes, what was repaired? Was repair done under inspection? Yes No VjWere soil samples analyzed? Yes Pub No Score 10 pts if condition is met BTXE T,,n TPH-G Score 5 pis if condition is met TPH-D ft; ft; ft Pb/EDB V. Site Feature - Leaching Potential Analysis Type of failure/discharge catastrophic long-term leakage 15 overfill Fractures in subsurface (applies to foothills or mountain areas) unknown None other: •• .... •..• •, .,..�� .ni�n�n .n arc�n�n 6CrVKI rwe aLIC utIA1LJ/GULLECT DATA FOR LEACHING POTEMTIAI 4WAIYSic1 Soil Samples Received Yes ✓ No Depth to Ground Water 07E Ref/Year NO Average Annual Precipitation A= 14 10-25 On -Site Wells) Yes No Number & Type Irr Dom Pub S C 0 R E Score 10 pts if condition is met S C 0 R E T,,n Score 5 pis if condition is met Distance to Wells) from Tank ft; ft; ft V. Site Feature - Leaching Potential Analysis Minimum Depth to groundwater from the Soil Sample (feet) >100 51-100 15 25-50\1 Fractures in subsurface (applies to foothills or mountain areas) None Unknown Present Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 Man -Made conduits which increase vertical migration of leachate (i.e., septic systems, water wells, ponds) l0 None Unknown Present Unique site features: Recharge area, coarse soil, nearby wells. xxxxxx None At Least one More than one COLUMN TOTALS>>>TOTAL POINTS ♦ + f _ Semple Result: (B T X OR E) _ 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 B .3 T 3 X 1. E 1. NA\3 Sample Result: L �•� TPH MAXIMUM ALLOWABLE TPH LEVELS (PPM) GASOLINE 1000 100 70 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 If depth is > 5 ft. and < 25 ft., score 0 points. If 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). . STAFF RECOMMENDATION/CONCLUSION 1. Are BTX & E or TPH Concent rad o s > Allowable LeveLs *Yes No 2. Recommend Site Closure Yes No If Yes, Refer to Site Mitigation for Evaluation 1. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR CONCUR,,WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO DATE REFERRED / / DATE CLOSURE LETTER MAILED NAME OF EVALUATOR