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it <br /> SAN JCAQUIM-^ RUSLIC HEALTH SERVICES/E?IVIRCNMENTAL HEAi^tvlsrcu <br /> :. T WORKSHEET FOR SITE CL05URE sVALUATICN - DATE1 <br /> :r <br /> NAME OF FACILITY :# SWE=.oS CC10E� <br /> IADDRESS �TANK IQ3 <br /> iTANK SIZE1 (FUEL TYPE G�S� VIE i1 <br /> ;E. GENERAL SITE HISTCRY li <br /> 'E <br /> Is permit current? Yes NoPermit N - Facility Status Cade Doc.SaiE/GW Cant Yes Nal <br /> I I <br /> Nunber of Tanks at facility (Age of Tanks(if avaitaoLe)I L 1T9pe of 'rank SteeL1ESngL1 Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yesl 1Ho Failed precision test ? Yes 1Nol lIf yes; give <br /> was a repair made to the :ank system, Yesl MGM <br /> a If yes, what was repaired7li M <br /> 1Was repair done under inspectionllYesl 1Nal Were soil same{es anaLyzed? Yes 1Nal STXEI 174-G TPH-41 1Pb/EDB <br /> Type of failure/discharge lcatasrraphic (Fang-terse Leakagel IaverfiEEl 1 'a' l i�lacher: <br /> (V. .REMOVAL HISTORY (ATTACH INSPECTION WORT FOR SITE DETAILS/CCLL;CT DATA FOR LEACHING PMNTIAL ANALYSIS) <br /> Sail Samples Received Yes=01 <br /> epth to Ground Water �](� 1Ref/Year{ O W ; Average AnnuaL PrecipitationjA= 14. 110-25 <br /> 1 <br /> On-Site WeLL(s){Yes l 1me `Number & Type 1 Irr (Dom 1Publ y <br /> S Score S Score S Score <br /> Distance to WetL(s) from Tank ft; ft; ft G 101,pts C 4 pts C 5 pts <br /> O if O if 0 if <br /> R condition R condition R condition <br /> V. Site Feature - Leaching Potential Analysis E is,met is met E is met <br /> Minimum Depth to groundwater from the Sail Sampte (feet) rid— 1 ��r54 1 }BOO 1 I 151-100 1 1 25-50\1 <br /> lFrac.ures in suasurrace Cappiies to foothitls or mountain areas) ,Vane 1 Unknaun Present <br /> Average AnnuaL Precipitation (inches) lxxxxxxl <40 f 9 1 10-25 lxxxxxxxl 26-40\2 <br /> 7 (Nan-Made conduits which increase verticaL migration lPresent <br /> of leadlate (i.e., septic systems, water weELs, ponds) Yarre Unknown I <br /> (Unique site features: Recharge area, coarse soil, nearby weds. AL Least More than <br /> xxxxxx Kane ane one <br /> :j <br /> COLUMN TCTALS>»TOTAL POINTS I I 3 I ` v I f'[Q <br /> Sample Result: (B T X OR E) RANG OF TOTAL POINTS 49 pts or'jaore 1 41 - 48 pts 40 pts or Less <br /> � �o rue✓ 3 3r <br /> MAXIMUM ALLOWABLE 3-r-X-5 LEVELS MON) 11 50l 5Q1 50 .3 1.3 I 1_� 1. �� NA\3 <br /> Sampte Re ult:� 3Q0 GASOL.HE 10001 1 100 1 t0 <br /> TJ� .) MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> rf1 I Ly �- rPH D DIESEL 10,am 1 lam 100 <br /> �.FOOTNOTES. " If documented soil and/or ground water contamination is presist, da;l comptete a leaching potential <br /> analysis. (i.e., site is currently an UGT Contamination Lisz�ifor sail or ground water.) <br /> \1 If depth is s 5 ft. and < 25 ft., scare 0 points. If depth M�- ft.,'Ido not use tabte. <br /> \2 If precipitation is ? 40 inches, score 0 points. I <br /> \3 Levets for 3TX&E are not applicable at a TPH concentration of to PM (gasaiine) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/=XCLUSION <br /> 1. Are 3TX & E or TPH Concentrations > ALLowabie Levels I"esTNA No <br /> 2. Recawxwid Site Closure Yes 1Nol 1a'If Yes, Refer to Site Mitigation for Evaiearion <br /> VII. REVIEW EVALUATICH - TO 3E COMPM..FrED BY A SUPERVISOR/SEHIOR iM <br /> CCHCUR WITH STAFF RECCMME'IDATICN FCR CLOSURE YES I 1 N01 I REF"E'RRED i O SITE MIT GATTON FCR EiIALLW7ION 1 YE5 I NO <br /> DATE REFERRED / / JDATE CLOSURE LETTER mAILED1 <br /> NAME OF <br /> EVALUATCRI <br /> Eli 23 30 (UGTWKSHT)\5/90 <br />