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SAN JCAOIII. PLBLIC , HEALTH SERVICES/ERVIRONNENTAL l \ DIVISION <br /> [ . . WORKSHEET FOR SITE CLOSURE EVALUATION DATE1 <br /> NAME OF FACILITT �i�'-1V � i%l.L)`� SZNE3S CCOE1 <br /> ADORESSI 1 2,0 1 f5i � - TANK ID i <br /> TANK SIL ?�j WD FUEL TYPE <br /> lI . GENERAL SITE NI STORY <br /> Is permit current? Yes No Permit i1 - Feciliry Status Code Doc. sail/GW Cmx Yell Mol <br /> Nunber of Tanks at facilitylAR of Tanks( If available) Type of Tank Steal FbrgtSML DML <br /> III . TARK HISTORY <br /> Was Tank tested? Yes No si Led precision test ? Yes No It yes , give dates) <br /> Was a repair made to the tank system? Yes b If yes , what, vas repaired? <br /> Was repair done uMer inspection? Tes Nol (Were soil samples analyzed? Yes No DTXE TPN-G TPH-01 IPb/IDB <br /> Type of failure/discharge) atastrophicl hong- term Leakageoverfill �rilaw�n other: <br /> IV. REMOVAL HISTORY (ATTACH INSP ION RESORT FOR SITE DETA /COL DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> soil Samples Received Yes I U1No Depth to Grand Wa r V Ref ear j4yo Average Annie [ Precipitation A.ltt. 170-25 <br /> On-site WeLL (s) Yes Na Number L Type' Irr Pub <br /> S score S Score S Score <br /> Distance to WeLI (s ) from Tank ft; ft; ft C 10 pts C 9 pU C 5 <br /> 0 if 0if 1 <br /> R condition R It on R eaudi tum <br /> v. Site Feature - Leaching Potential Analysis E is met E is , t ` is mac <br /> Minimum Depth to groundwater from the Soil Sample Cfeet) 1 >100 1 }= 1 125-50\1 <br /> Fractures in . subsurface (appLies to foothills or mountain areas) None - ) V Urilafonn I IPr*smc <br /> Average Amual Precipitation ( inches) :000CCE Al ;\J' <br /> 9 10-25 1 l zs-4D\z <br /> Xan-Made conduits Which increase vertical agratim <br /> of leachate ( i . e. , septic systems, water Wells, ponds) one Unknown Present <br /> Unique site features : Recharge area, coarse soil , nearby we( l �f At Least )bre than <br /> UNone ane one <br /> COLIDq TOTALS»TOI'AC POINTS I + I + <br /> Sample Result: �y(3�T ✓XOR J wyrRANGE OF OTAL POINTS 49 pts or more I 47 - GS pts 40 pts or less <br /> 6 � J MAXIM[D( ALLMAZ a R-T-X-E LEVELS (PPM) I soI SoI 50 .3 I .3 1 . 1 . KA\3 <br /> Sample Result: GASOLINE 1000 I 100 to <br /> UM <br /> MAXIMA�� TPH LAMS (PPM) <br /> i ` I ll �pAI DIESEL 10, 000 Iwo 100 <br /> i <br /> FOOTNOTES: ' If donmented soil arWr 9rard water contamination is present, do not complete the Leaching potential <br /> enalysfs. ( i .e., site is currently on UGT Contamination List for soil or grand water. ) <br /> \1 If depth is > 5 ft. and < 25 ft. , score 0 points. If depth ni ft. , do not use cable. <br /> \2 If precipitation is > W in cbes , scar* 0 pointse <br /> \3 levels for BTXLE are roc applicable at a TPN concentration of 10 <br /> ppm (gasoline) or 100 ppm (diesel) - <br /> VI . STAFF RECO44EMDATICM/CONCLUSION <br /> 4 <br /> 1 . Are BIX L E or TPtl Coneentretiona > AI[oubla Levels I *Yes No <br /> Z. Recommend Site Closure Yes Mo If Too , Refer to Site Mitigation for Eveluation <br /> VII . REVIEW EVALUATION - TO SE COMPLETED A SUPERVISaUSERICR <br /> C7NCl1R WITH STAFF RECCGeMATIOM FOR CiLSpFITES NO REFERRED TO SITE MITIGATION FOR 6VALLIATICRIYESIZ, + 1 <br /> DATE REFERRED1 DATE CLOSURE LETTER MAILED ` <br /> NAME OF <br /> EVALUATOR <br /> i <br /> EH Z3 90 (UGTW1(SHT)\$/90 <br />