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SAN JOACCUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAALTH DIVISION <br /> I, UGST 'JORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY © L I <br /> SWEEPS CODE a 3 a Q 8 I <br /> ADDRESS �' �' TANK ID *13 <br /> TANK SIZE 3— FUEL TYPE -L�yyv�4- 1 Iv ( ne— <br /> II. GENERAL SITE HISTORY 9 <br /> IIs permit current?IYes Nol (Permit * - Facility Status Code Doc-SaiL/GW Cont Yes INo <br /> Num ( <br /> ber of Tanks at facility Age of Tanks(if available) (Type of Tank Steell IFbrgll ISngt Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision testf yes, give date(s) <br /> ? Yes Na t <br /> was a repair made to the tank system?(YesI Nol If yes, what was repaired?( <br /> Was repair done under inspections Yes Nol IWere soil samples analyzed? Yesl INo I3TXEI (TPH-GI TPN-0I Pb/EDB( <br /> Type of failure/discharge) catastrophicI (Long-term Leakage 1overfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSTS) <br /> Soil Samples Received Yes INo (Depth to Ground Water Ref/Year Average AnnuaL Precipitation A= 14 10-25 <br /> Ion-Site Wells) Yes Nol INunber 3 Typel lrr ! Dao Publ S Score S Score s Score <br /> Distance to WeIL(s) from rank it; ft; ft C 10 pts C 9 pts C 5 pis <br /> 0 if 0 if 0 if <br /> R condition R condition R condition <br /> V. Site Feature • Leaching Potential Analysis is met E is met E is met <br /> �Minimum Depth to groundwater from the Soil Sample (feet) 7 Q�� d i >100 I51-100 I 25-50V <br /> Fractures in subsurface (applies to foothills or mountain areas) D I None I Unknown I (Present <br /> ?Average Annual Precipitation (inches) xxxxx:c I <to I 9 110-25 xxxxxxx 26-40\2 <br /> (Man-Made conduits which increase vertical migration <br /> ,of leachate (i.e., septic systems, water wells, ponds) / None Unknown I Presenr <br /> 'Unique site features: Recharge area, coarse soil, nearby wells. A At Least More than <br /> �A pp 4 xxxxxx None 1 ane) one <br /> Pl 'YIru ' COL LS»TOTAL POINTS <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more I 41 - 48 pts 40 pts or less <br /> PsY x= .oat�b► <br /> C S T X E 8 T X E <br /> P ,}3F- 3 MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 I.3 1. 1. NA\3 <br /> Sample Result: GASOLINE 1000 100 I 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH DIESEL 10,000 1000 100 <br /> FOOTNOTES: —If documented soil and/or groud water contamination is present, do not complete the Leaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for sail or ground water.) <br /> \1 if depth is > 5 ft. and < 25 ft., score 0 points. If depth < 5 ft., do not use cable. <br /> \2 If precipitation is > 40 inches, score 0 Points- <br /> \3 Levels for BTXBE are not applicable at a TPM concentration of 10 ppm (gasoline) or 100 ppm (diesel)- <br /> Vt. STAFF RECOMMIE4DATION/CONCLUSION P3 <br /> 1. Are BTX S E or TPH Concentrations > Allowable levels (-Yes No <br /> gt = 1,3 <br /> 2. Recommend SiteClosure Yes NC If Yes, Refer to Site Mitigation for Evaluation ` a l+.- r. O )� <br /> VII. REVIEW EVALUATION - TO BE COMPLETED 8Y A SUPERVISOR/SENIOR 1 -0���,� . ORO <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE(YES( NOI (REFERRED TO SITE MITIGATION FOR EVALUATIONIYESI IND <br /> DATE REFERRED / / (DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> E`/ALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />