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i SAM JOAQUIN ccr^11 PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL"' IVISIOH / I. j WORKSHEET FOR SITE: CLOSURE EVALUATION DATE yf� S rt/3 NAME OF FACILITYe-✓✓�H -SWEEPS CODE l/ 3 ADDRESS S/(o l -u cls`- clG. irr TANK ID # i TANK SIZE l O� EL TYPE II. GENERAL SITE HISTORY Is permit current? Yes NoPermit tl Facility Status Code ,5� Doc.Soil/GLI Cont Yes No Number of Tanks at facility /!/ Age of Tanks(if available) Type of Tank Steele Fbrgl Sngl Dual III. TANK HISTORY Was Tank tested? Yes Na I V failed precision test ? Yes No If yes, give date(s) Was a repair made to the tank system? Yes No If yes, what was repaired? IIWas repair done under inspection? Yes No Were soil samples analyzed? Yes No STXE TPH-G TPN-D Pb/EDB Type of failure/discharge catastrophic long-term leakage overfill unknown other: IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR eiT` " )LLECT DATA FOR LEACHING POTENTIAL ANALYSIS) $oil Samples Received Yes Ref/Year f q Average Annual Precipitation A= 14 10-25 On-Site Welts) Yes No 5 Score S Score S Scare Distance to Welt(s) from Tank K �ft C 10 if pts p 9fpts C if R condition R conditlon R condition V. Site Feature - Leaching Po- ` E is met E is met E is met Minimum Depth to groundwater ft _ >100 51-100 S 25-50\1 Fractures in subsurface (applie.-co Toothi[ls or mountain areas) None Unknown Present Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 Man-Made conduits which increase vertical migration of leachate (i.e., septic systems, water wells, ponds) None Unknown Present Unique site features: Recharge area, coarse soil„ nearby welts. At Least More than xxxxxx None �' one one COLUMN TOTALS»>TOTAL POINTS + 310 + Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 4T - 48 pts 40 pts or less ,/ M `�P^? S T X B T X E l� MAXIMUM ALLOUABLE B-T-X-E LEVELS (PPM) 1 50 50 0 .3 .3 1. 1. MA\3 Sample Result: ' GASOLINE 1000 100 10 MAXIMUM ALLOWABLE TPH LEVELS (PP ' 70D elnj PH DIESEL 10,000 1000 100 FOOTNOTES: ***If documented soft and/or ground water contamination is present, t complete t leaching potential analysis. (i.e., site is currently on UGT Contamination List fo ground water.) \1 if depth is > 5'ft. and < 25 ft., score-0 points. if depth <=5 ft., do not use table. \2 If precipitation is > 40 inches, score 0 points. \3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). VI. STAFF RECOMMENDATION/CONCLUSION Ace 1. Are STX & E or TPH Concentrations > Allowable Levels *Yes No 2. Recommend Site Closure Yes No *If Yes, Refer to Site Mitigation for Evaluation VIt. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES MO REFERRED TO SITE MITIGATION FOR EVALUATION TES NO DATE REFERRED / / DATE CLOSURE LETTER MAILED NAME OF EVALUATOR EH 23 80 (UGTWKSHT)\5/90