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SAH JOAQUIN CO' PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA[ IVISION i <br /> 1, WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME DF FACILITY G' SWEEPS CODE <br /> 113 <br /> r� <br /> ADDRESS leu. � c•- S �/ TANK ID # S c% r'I{ fxs K <br /> TANK SIZE L TYPE <br /> i <br /> It. GENERAL SITE HISTORY <br /> 54 <br /> Is permit current? Yes . No x Permit # Facility Status Code Doc.SoiIIGW Cont Yes Ho " <br /> Number of Tanks at facility /l/ Age of Tanks(if available) Type of Tank Steel rgl Sngl Dual <br /> I <br /> 11I. TANK HISTORY <br /> Was Tank tested? Yes No ailed precision tY <br /> Yes Ho If yes, give dates) / <br /> Was a repair made to the tank system? Yes Noyes, what was repaired? <br /> Was repair done under inspection? Yes No Were soil samples analyzed? Yes No BTXE TPH-G TPH-D Pb/EDB <br /> I <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 Water ( Ref/Year c��;� Average Annual Precipitation As 14 10-25 <br /> On-Site Welts) Yes No Number & Type Irr. Dom Pub <br /> S Score S Score S Scare <br /> Distance to Well(S) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R condition R condition R condition <br /> V. Site Feature - Leaching Potential Anatysis �?/= E is met E is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet) 27 >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown Present <br /> Average Annual Precipitation (inches) XXXXXX <10 9 10-25 xxxxxxx 26-40\2 <br /> Nan-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water watts, ponds) Hone Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> xxxxxx None one one <br /> r� <br /> COLUMN TOTALS»>TOTAL POINTS" 3L i r <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 413 p 40 pts or toss <br /> 81 T % B T X E <br /> = - �� MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 f <br /> .3 .3 1. 1. NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TAH LEVELS (PPM) <br /> L(� TPH C, DIESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do no omelet the leaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for so r ground water.) <br /> \1 If depth is > 5 ft. and < 25 it., score 0 points. if depth «5 ft.., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for 8TX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> C r o'.2r` <br /> 1. Are 8TX $ E or TPH Concentrations >-At lovable Levels *Yes Ho c e "e �� <br /> 2. Recommend Site Closure Yes No if Yes, Refer to Site Mitigation for Evaluation <br /> VIT. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE Y£S NO REFERRED TO SITE MITIGATION FOR EVALUATION YES HO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />