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SAN JOAOUI,. ITY PUBLIC HEALTH SERVICES/ENVIRONMENTAL aSAH DIVISION <br /> UGST WORKSHEET FOR SITE CLOSURE: EVALUATIOA OATE <br /> NAME OF FACILITY +pG �"t �vv Sf SWEEPS COOS lig <br /> ADDRESS QQ 3 iF• TANK ID <br /> TANK S12E jd FUEL TYPE <br /> 11. GENERAL SITE HISTORY ..� <br /> Is permit current? Yes No Permit 0 - Facility Status Code Doc.Soil/GW Cont Yes No <br /> Number of Tanks at facility Age of Tanka(If available) Type of Tank Steel fbrgt Sngl Dual <br /> II1. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test T Yea No If yes, give date(s) <br /> Was a repair made to the tank system? Yes No If yes, whet was repaired? i <br /> Was repair done under inspection? Yes No Were soil samples analyzed? Yes No BTXE TPH-G TPH-D Pb/ D8 <br /> Type of failure/discharge catastrophic long-term leakage overfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Ground Vater Ref/Tear �'�; Average Arnuel Preelpitetion A= 14 10-25 <br /> � <br /> On-Site Well(s) Yes No Number & Type Irr Dom Pub <br /> S Score S Score �'. 5 Score <br /> Distance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C 15 pts <br /> 0 if 0 If 0 if <br /> R condition R condition R condition <br />€ V. Site Feature - Leaching Potential Analysis E is met E <br /> is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet)— j (�=L�[1 >100 51-100 25-50\) <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown. Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 28-44\2 <br /> Man-Made conduits which Increase vertical migration Unknown Present <br /> of leachate (i.e., septic systems, water wells, ponds) None <br /> Unique site features: Recharge are coarse soil, nearby wells. At least More than <br /> xxxxxx None one one <br /> q :t <br /> COLUMN TOTALS»> ; <br /> TOTAL POINTS �� + <br /> 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 /> 11 /11 �� B T X E B JT X E: <br /> !f IV Wi}yM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Semple Result: '�#� GASOLINE 1000 100 1 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> agm—TPH-D DIESEL 10,000 1000 100 <br /> i FOOTNOTES: ***If documented soil and/or ground water contamination Is present, do not complete the eoching po en at <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth ­5 ft., do not use table. <br /> \2 if precipitation Is > 40 inches, score 0 points. ppm (diesel). <br /> \3 Levels for BTXBE are not applicable at a TPH concentration of 10 (gasoline) or ;1 <br /> p� 00 <br /> VI. STAFF RECOMMENDATION/CONCLUSION ' <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels -Yes <br /> ' <br /> Z. Recommend Stti ClnsUre Yes NO if Y*t, Rofer to Sit• Nit1gation for Evelaation <br /> * <br /> i <br /> j VII- REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YESNp REFERRED TO SITE MITIGATION FOR EVALUATION YES &"IHOLI <br /> i <br /> DATE REFERRED (2 DATE CLOSURE LETTER MAILED / I <br /> NAME OF <br /> EVALUATOR - 1 <br /> f <br /> EH 23 80 (UGTWKSHT)\5/94 <br />