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SAN ,10AQUIN C PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL DIVISION <br /> I WORKSHEET FOR SITE CLOSURE EVALUATION DATE $ C13 <br /> NAME OF FACILITY SWEEPS COOS <br /> �° � e u rc�n��•: <br /> ADDRESS / y[p �C cz:c Gr/K {�-� S U TANK ID # 3 7 - //3�-- C, 4 <br /> 1 <br /> TANK SIZE lO/000 FUEL TYPE uyi/tea�ecr <br /> II. GENERAL SITE HISTORY *** <br /> Is permit current? Yes No Permit # -F Facility Status Code Doc.Soil/GW Cont Yes No <br /> Number of Tanks at facility !� Age of Tanks(if available) Uk, Type of Tank Steel I qKrgl I Sn-glO� Dual <br /> LEI. TANK HISTORY <br /> Was Tank tested? Yes Na Failed precision test ? Yes No if yes, give date(s) / ! � <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? <br /> Was repair done under inspection? Yes No Were soil samples analyzed? Yes No BTXE TPH-G ,.' TPH-0 Ph/EDB <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 fgpAverage Annual Precipitation A=114 10-25 <br /> On-Site Wells) Yes No umber A Type Err Dam -Pub <br /> S Score S Score S Scare <br /> Oistenee rn uei�re� sem. . �- ft; 5 pts <br /> ft C 10 pts C 9 pts C <br /> 0 if 0 if 0 if <br /> R condition R condition R condition <br /> 4, E is met E is met E is met <br /> `Ple (feet) r >100 51-180 25-50\1 <br /> or mountain areas) None / Unknown Present <br /> xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> tion None Unknown Present <br /> .ponds) <br /> W. nearby wells. At least More than <br /> xxxxxx None one one <br /> TS 3 <br /> RANGE OF TOTAL POINTS 49 pts or more 1 - 48 pts 40 pts or Less <br /> B T X B T X. E. <br /> lE (P <br /> B-T-X-E LEVELS (PPM} 1 50 50 5o .3 .3 11NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH DIESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, da not complete a leaching potential <br /> analysis. (i.e., site is currently an UGT contamination Lt for soil ground water.) <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth —5 ft., use table. <br /> \2 if precipitation is > 40 inches, score 0 points. <br /> \3.Levels for BTX&E are not applicable at a TPH concentration of 10-ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION ! <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes I V No $ so .� p dor <br /> a{ <br /> Z. Recommend Site Closure Yes No If Yea, Refer to Site.Mitigation for Evaluation <br /> VIE. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR ENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YE5 HO <br /> OATS REFERRED / ` [( ! GATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EN 23 80 (UGTWKSHT)\5/90 <br />