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i <br /> SAN JOAOUL- . .,ry PUBLIC HEALTH SERVICES/ENVIRONMENTAL 9_ _ DIVISION <br /> I ' UGST WORKSHEET FOR SITE CLOSURE <br /> EVALUATION <br /> DAT-E <br /> NAME OF PACLITY 1S4E' 5 CI? <br /> WE <br /> ADDRESS3 I '�( 7 I vCJ_�1V i <br /> _ <br /> c _ TANK ID '. O <br /> DANK SIZE ( rQ, CJ&) ( FUEL TYPEIF� <br /> 11 . G-cNE.RAL SITE HISTORY <br /> Is permit current? I Yesl Nal ( PermitIFaci Liry Status Cadel0 r lOac.Soil/GV 1 I 1 l <br /> Conr Yes Na <br /> INumaer of Tanks at facility Age of ianks( if available) lCr{ ( Type of TanklSteell lFhrg( l ISng( l 0ua ( <br /> III , LANK HISTORY <br /> Vas Tank casted? Yes Ha ( Fatted precision ;est ? I Yes ) INoI If yes , give dare( s ) Vv/3/ / ii / <br /> Was a repair made to the tank s �UI / <br /> ystem? IYesl No lif yes , what was repaired? ( -<- " -�' - � � q �Z,�� <br /> Was repair done under inspection? IYesl INoI lVere sail Samples analyzed? I <br /> i Yes � No STXEITPH-G � <br /> TPH-0 <br /> I Pb I I I I /SBI <br /> Type of ,^'ailuro/discharge catastrophic fang- cerin Leakage I I 9e � overfill unknown <br /> L I ' I l I Icther: <br /> IV . REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITEE OETAILS/COLLPCT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> ( Soil Sartples -ReceivedlYesl No Depth ;o Ground Vater <br /> 1 I 1 Ref/Year I ( Average Ahhual Precipitation ) A= 14 110- 25 <br /> On- Site Well ( s ) YesNo ( Number 3 iype IIrrI ) Open) IPuoi <br /> S Scare <br /> Distance to VeIL ( s ) from lank S Scare S Score <br /> rt; - C 10 Pts C 9 Pts C 5 pts <br /> 0 if O if 0 if <br /> V . Site Feature - Leaching Potential Analysis . ? condition R condirion R conditi on <br /> is met is net - is met <br /> ( Minimum Depth m groundwater from the Sail Sample < feet ) > 100 <br /> I ISI - IGO I 125-50\ 1 l <br /> Fractures in Subsurface ( applies to foothills or mountain areas ) <br /> I Hone l UnknownI Present <br /> Average Annual Precipitation ( inches ) xixXXxl <10 l <br /> 9 I to-25 IXX)c=XI 25-40\Z <br /> lMan-Made conduits which increase vertical migration <br /> of ( eachare ( i . e. , Septic systems , water wells , ponds ) <br /> .Vane I I Unknown I ( Present <br /> IUnique site features : ,Reclharge area, coarse soiL , nearby wells . L_ <br /> At l More than <br /> xz:octx Vone <br /> COLUMN TOTALS» we one <br /> >TOTAL POINTS r y <br /> 1 = <br /> Sample Result : B T X OR -) RANGE OF TOTAL POINTS 49 pts or more I 41 - 4d <br /> (I'U �!2 U ��� C � pts I G0 pts or less <br /> �- --- 9 T X <br /> MAXIMUM ALLOWABLE 3-i-X-? LS (PPM) 1I 50I 50I <br /> i 3 <br /> sample Result : <br /> g�)J06n GASOLINE 1000 l 100 l <br /> r '11 MAXIMUM ALLOWABLE TPH LEVELS (PPM) 7D <br />!T jt (�^ ->�_�TPH3 DIESEL 10, a0a 1000 l 100 <br /> FOOTNOTES : " Tf documented soil and/or ground water canramination is Present, do not complete the leaching potertiaL <br /> analysis_ ( i .e. , sire is currently on UGT Contamination List for sail or ground water . ) <br /> \ 1 If depth is > 5 ft- and < 25 ft. , scare 0 points. If <br /> depth �s\2 If precipitation is > 40 inches , score 0 Points_ ft. , do not use table_ <br /> \3 Levels for BTXEE are nor applicable at a TPR concentration Of TO ppm (.gasoline) or 100 ppm (diesel ) . <br /> VI . STAFF RECOMMENDATION/CONCLUSICM <br /> 1 . Are BTX S E or TPH Concentrations > ALLowab(e Levels ( 'Yes ( NoI <br /> 2 . Recommend Site Closure Yes ( NoI JC I If Yes , Refer co Site Mitigation for ° aluarion <br />/11 . .-RREVIEW EVALUATION - 10 SE COMPLETED13Y A (SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSUREIYESI INOI ( REFERRED TO SITE MITIGATION FOR EVALUATICNIYESI INOI I <br /> R2380 <br /> RED ( / / IRATE CLOSURE LETTER 4AILED1 / <br /> / <br /> EH (UGTWKSHT ) \5 /90 <br />