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(, <br />SAN JOAOUI�' "'UNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL <br />UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br />Nr,".TH DIVISION <br />DATE <br />Failed precision test ? Yes iNo <br />NAME OF FACILITY <br />(SWEEPS CODE <br />Was repair done under inspection? Yes <br />ADDRESS L/' <br />/ ;� 1 �L/� <br />/�� <br />TANK IDl <br />TANK SIZE f <br />FUEL TYPE . 'G <br />overfill) <br />unknown <br />other: <br />*r* <br />permit current? Yes No Permit 4 Facility Status Code Doc.Soil/GW Cant Yes No <br />m ber of Tanks at facility Age of Tanks(if available) Type of Tank Steep Fbrgl Sngl Dual <br />III. TANK HISTORY <br />Was Tank tested? <br />Yes <br />No <br />Failed precision test ? Yes iNo <br />If yes, give date(s) <br />Was a repair made to the tank system? Yes <br />i <br />No If yes, what was repaired?! <br />Was repair done under inspection? Yes <br />NoI Were soil samples analyzed? Yes NoI <br />On -Site Wells) <br />BT XEI ITPH-G TPH-D Pb/EDB <br />No <br />Type of failure/discharge (catastrophic <br />long-term Leakage <br />overfill) <br />unknown <br />other: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />Soil Samples Received Yes <br />No <br />Depth to Ground Water <br />Ref/Year <br />Average Annual Precipitation <br />A= <br />14 <br />10-25 <br />On -Site Wells) <br />Yes <br />No <br />Number & Type Irr <br />Dom <br />Pub <br />S <br />Score <br />S <br />Score <br />S <br />Score <br />Distance to Well(s) from Tank ft; ft; ft <br />C <br />10 pts <br />C <br />9 Pts <br />C <br />5 pts <br />0 <br />if <br />0 <br />if <br />0 <br />if <br />R <br />condition <br />R <br />condition <br />R <br />condition <br />V. Site Feature - Leaching Potential Analysis <br />_ <br />is met <br />E <br />is .met <br />E <br />is met <br />Minimum Depth to groundwater from the Soil Sample (feet) <br />>100 I <br />151-100 <br />75-50\1 <br />Fractures in subsurface (applies to foothills or mountain areas) <br />None <br />i <br />Unknown <br />Present <br />Average Annual Precipitation (inches) <br />xxxxxx <br /><10 <br />9 10-25 <br />xxxxxxx+ <br />26-40\2 <br />Man -Made conduits which increase vertical migration <br />of leachate (i.e., septic systems, water wells, ponds) <br />None <br />I Unknown <br />Present <br />Unique site features: Recharge area, coarse soil, nearby wells. <br />At least <br />More than <br />xxxxxx <br />None <br />I <br />one <br />one <br />COLUMN TOTALS>>>TOTAL POINTS <br />+ <br />I + <br />Sample Result: (B T X OR E) <br />RANGE OF TOTAL POINTS <br />49 pts <br />or more 41 - 48 pts <br />I 40 pts or less <br />BI T <br />X I EB <br />T I X <br />E <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) <br />11 50 <br />50I 50 <br />.3 <br />.3 1. <br />1. <br />NA\3 <br />Sample Result:GASOLINE <br />1000 I 100 <br />10 <br />MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br />DIESEL <br />10,000 1000 <br />100 <br />TPH <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 BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br />VI. STAFF RECOMMENDATION/CONCLUSION <br />1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No) <br />2. Recommend Site Closure IYes No If Yes, Refer to Site Mitigation for Evaluation <br />VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br />CONCUR WITH STAFF RECOMMENDATION FOR CLOSUREIYES NO (REFERRED TO SITE MITIGATION FOR EVALUATION YES( NOI <br />DATE REFERRED / / DATE CLOSURE LETTER MAILED <br />NAME OF <br />EVALUATOR <br />EH 23 80 (UGTWKSHT)\5/90 <br />