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SAN JOAOU I' ,,MWJBLIC HEALTH SERVICES/ENVIRONMENTAL -" ISI ON Q <br /> [, wu„ST WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY 7 SWE"c PS CODE <br /> ADDRESS 96 S TANK ID # -.`b <br /> r <br /> TANK SIZE /a FUEL TYPE <br /> 1I. GENERAL SITE HISTORY <br /> *** <br /> Is permit'currf Yes No Permit # - Facility Status Code ©I Doc.Soil/GW Cont Yes No <br /> Number of Tanks at facility Age of Tanks(if available) (;olTroa <br /> of Tank Steel M <br /> Fbrgl Sngt Dual <br /> 111. TANK HISTORY C&a ? <br /> Was Tank tested? Yes No Failed precision test ? 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 soil samples analyzed? Yes No BTXE TPH-G TPH-D 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 Ref/Year �to ; Average Annual Precipitation A= 14 10-25 1 19&1 <br /> On-Site Wells) Yes No Number 8 Type Irr Dom Pub <br /> S Score S Score S Score <br /> Distance to Wells) from Tank ft; ft; ft C 10 pts C 9 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 /> Minimum Depth to groundwater from the Soil Sample (feet) >100 51-100 JC 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) ' P None Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) I Q None Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. 4 At least More than <br /> xxxxxxx None / one one <br /> COLUMN TOTALS>>>TOTAL POINTS p6( + ' 0 + _ <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> rK = WE) <br /> B T % E B T I X E <br /> TK 3 = A)D 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 /> N D MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> At TPH DIESEL 10,000 1000 100 <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 BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION 5 ', <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels *Yes No vvt )O.F / 1 �� -P�'vUCJrBXq <br /> 2. Recommend Site Closure Yes to *If Yes, Refer to Site Mitigation for Evaluation 6"e <br /> VII. REVIEW EVALUATION - TO BE COMPL ED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />