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u _ <br /> SAM JOACllX CO' ' PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTY ^ LVISIOH DAT " <br /> WORKSHEET FOR SITE CLOSURE EVALUATION <br /> NAME OF FACILITY U �� E1 G.� r�2. JIWIC D`�1 SWEEPS CODE <br /> ADDRESS � G Cj{/1.QA/+t' r w J\L�Lh- 18Y1 l�( C16TANK ID X <br /> TANK SIZE13 Y. 12kobog FUEL TYPE " <br /> I . GENERAL SITE HISTORY <br /> ( s permit current? Yes <br /> No 2 Permit tl - Facility Status Code Doc . Soil/ GL Con[ Yes No <br /> Nunber of Tanks at facility3 Age of Tanks ( if available ) Type at Tank Steel Fbrgl Sngl Dual <br /> Il . TANK HISTORY <br /> iWas Tank tested? Yes No Failed precision test 7 Yes No If yes , give date( s ) <br /> iWas a repair made to the tank system? Yea ✓/ No If yes , what was repaired? NaN 9ILWtFd5 <br /> Was repair done order irepecci on7 Yes No Were soil samples analyzed? Yes Na BTXE TPH • G TPH -D - Pb/ED8 <br /> Type of failure/discharge catastrophic long- term leakage overfill nnkrwwn other : <br /> ; V . REMOVAL HISTORY (ATTACH IMSP£CTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS ) <br /> �( � A �( � Average Annual Precipitation Am 14 10- 25 <br /> Soil Sanplas Received Yes No Depth to Ground Water T" Ref/Year <br /> On- Site Wells ) Yes No N t Type Irr Dam Pub S Scare S Scare S Scare <br /> f 0 if 0 <br /> C pts C pts C <br /> Distance to WeLI ( s ) frac Tank ft ; fr ft i pts <br /> 0 if if <br /> R condition R condition R condition <br /> E is met E is met E is mac <br /> IV . Site Feature - Leaching Potential Analysis <br /> INininsm Depth to groundwater from the Soil Sample ( feat ) <br /> - > 100 51 . 100 5 25 -50\1 <br /> Fractures in subsurface Capplies to foothills or mas:cain areas ) <br /> None Q Unknown Present <br /> Average Annual Precipitation ( inches ) <br /> xxxxxx <10 9 10. 25 xxxxzrx 26- 40\2 <br /> Man- Made conduits which increase vertiul migration None , present <br /> of leachate ( i . e . , septic systems , water wells , ponds ) <br /> AL least More then <br /> unique site features : Recharge area , coarse soil , nearby wells . xxxxzx None are one! <br /> COLUMN TOTALS»>TOTAL POINTS i <br /> Sample Result : (B T X OR E ) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> nIkv B T X E B T X E <br /> E= 3 i'AlE 644 MAXIMUM ALLOWABLE B •T•X• E LEVELS (PPM ) 1 50 50 50 .3 .3 NA\3 <br /> GASOLINE 1000 100 10 <br /> Sample Result : <br /> ALLOWABLE LEVELS (PPM ) <br /> � � pp TPH MAXIMUM ALDIESEL 10 , 000 1000 100 <br /> FOOTNOTES : "' If documented soil and/or grand "tar contamination is present , do not complete the leaching potential <br /> analysis . ( i . e . , site is currentLY on UST Contamination List for soil or ground water . ) <br /> \1 If depth is > 5 ft . and < 25 ft . , score 0 points . If depth d5 ft . , do not use table. <br /> \2 If precipitation is > 40 inches , score 0 points . <br /> \3 Levels for BTXEE are not applicable at a TPH concentration of 10 ppm ( gasoline) Cr 100 ppm (diesel ) . <br /> VI , STAFF REC091E40ATI0N/CONCLUSION <br /> % Are BTX S E or TPH Concentrations > Allo"ble Levels 'Yes No <br /> 2 . Recanmerd Site Closure Yes No If Yes , Refer to Sita Mitigation for Evaluation <br /> VII . REVIEW EVALUATICN TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> WINES <br /> CGNCJR WITH STAFF RECCmmENDATION FOR CLCSJRE YES NOREFERRED TO SITE MITTEL LION FOR EVALUATION YE C <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH Z3 80 (UGTWKSHT ) 0 - <br />