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SAA JOAQUEN COULTYsPUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> JORKSHEET FOR SITE CLOSURE EVALUATION 'i �_ DATE <br /> NAME OF FACILITY � _ � i� �� .._PS COOS 1 <br /> .s <br /> ADDRESS ' i TANK ID N - f <br /> I <br /> TANK SIZE FUEL TYPE I <br /> i1 sto C�L ! <br /> r / <br /> II. GENERAL SITE HISTORY ;fir ;y <br /> II �� <br /> Is permit current? Yes No Permit N - r Facility Status Code 100 -Soit/GW Cont Yes No <br /> Number of Tanks at facility f Age of Tanks(if available) 3.. Type of,ETank Sleet Fbrgi Sng! Dual <br /> IIl. TAHX HISTORY <br /> Was Tank testeC7Yes Na Failed precision test ? Yes NoIf yes, give�date(s) <br /> i <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? j <br /> Was repeir done under inspection? Yes No Were snit samples analyzed? Yes No BTXE TPH-GTPM-D Pb/ED8 <br /> Type of failure/discharge catastrophic long-term Leakage overfill unknown other: <br /> IV. REMOVAL HISTORY (ATTAIN INSP ION REPORT FOR SITE OETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes VjNcj,,jDep0 to Ground WatertI ;� Average Arcual Precipitation A; 14 10-25 <br /> I <br /> On-Site Wetl(s) Yes No Number & Type Ire Dam pub <br /> S Score5 Scare S Score <br /> Distance to Wetl(s) from Tank ft; ft; ft C 10 pts .j C 9 pts C 5 pts <br /> 0 if O 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 Sampte (feet) ` 100 jg 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) D None Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9, 10-25 xxxxxxx 26-40\2 f <br /> Man-Made conduits which increase vertical migration !� <br /> Of leachate (i.e., septic systems, water wells, ponds) None q Unlasown Present <br /> Unique site features: Recharge area, coarse snit, nearby watts. j: At least More than <br /> xxxxxx None ;'� one one <br /> COLUMN TOTALS>»TOTAL POINTS O + 7 + Q <br /> Sample Result: (B T X OR E) RANGE Of TOTAL POINTS 49 pts or more ' 41 �4$ pts 40 pts or less <br /> B T X I E B T XE <br /> MAXIMIAI ALLOYABLE 9-T-X-E LEVELS (PPM) 1 50 50 50 ! .3 .3 1- 1. NA\3 <br /> I <br /> Sample Result: GASOLINE 1000100 10 <br /> 1) x I_'l. �}/L/MAXIMUM ALLOYABLE TPB LEVELS (PPM) <br /> W H DIESEL 10,000 1000 100 <br /> FOOTNOTES: "'If doe, ted It and/or ground water contamination is present, do not ate the teach ingpotential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil ar ground water.) <br /> \1 If depth is > 5 ft, and < 25 ft., score 0 points. If depth l#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 TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> 4 <br /> VI. STAFF RECOMEYDATION/CONCLUSION ik Ij <br /> 1. Are BTX 3 E or TPN Concentrati > A!! to Levels 'Yes No I it <br /> 2. Recommend Site Ctesure Yes Nv V if Yes, Refer to Site Mitigation for Evat-untion `Iy� a S "�'� 6SAA� <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR �� �n <br /> CCNC.lR WITH STAFF RECCKKEHDATION FOR CLOSURE YESNO REFERRED TO SITE MITIGATIQN FOR EVALUATION YES r NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATCR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> iE <br /> 3 <br />