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SAN JOAOUIK =f,7, PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL• JVISIOH <br /> WORKSHEET FOR SITE CLOSURE EVALUATION DATE �3 <br /> ILITY (�/' E Ps CODE114C ' <br /> 0 Co enL& <br /> �5 TANK ID <br /> SIZE FUEL TYPE <br /> .[ GENERAL SITE HISTORY jJ <br /> Is permit current? Yes No Permit - Facility Status Code Doc.Soit/aw Cont Yes No <br /> Number of Tanks at facility Aga of Tanks(lf available) Type of Tank Steel Fbrgl Sngl oual <br /> Ili. TANK HISTORY <br /> Rive date(S <br />€ Was Tank tested? Yrs No Failed precision test 7 Yes No If yes. g ; <br /> was a repair made to the tank system) Yrs No If yes, what was -repaired? + <br /> Was repair done under inspection? Yes No Were soil samples analyzed? Yes No1. BTXE TAH-G TPH-0 Pb/ED8 <br /> Type of failure/discharge catastrophic long-term leakage overfill jl <br /> unlcseoie+ 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 ; Average Arcual Precipitation A= 14 10-25 <br /> On-Site WeLL(s) Yes No Number & Type Irr Dam Pub <br /> 5 Scare S Scare S Score j <br /> Distance to Welt(s) from Tank ft; =ft; ft C 0 pts C 9 pts C 5 pts <br /> .. O 0 if 0 iif <br /># R c Ilion R condition R condition <br /> V. Site Feature - Leaching Potential Analysis E is t E is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet) >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown Present <br /> 1. Average Annumt Precipitation {inches) xxxxoc <10 10-25 xxxxnot 26-40\2 <br /> a <br /> Man-Made conduits which increase vertical migration <br /> of teachate (i.e., septic systems, water weLts, ponds) Nona / Unknown Present <br /> Unique site features: Recharge area, coarse sof L, nearby wells. / t least Mare than <br /> =aoac None one one <br /> COLIAIN TOTALSA»TOTAL POINTS <br /> {' Sample R lt-(B I X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pt 40 pts or less /� <br /> �i �ls �Pa � 4 '�i � B T X E B T X <br /> IAM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 5O .3 .3 1. 1. ,a/ RA\3 <br /> SaW a Result: j 3 GASOLINE loco 100 IO <br /> /� MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH {T 01ESEL 10,000 1000 1 <br /> FOOTNOTES: ***If documented salt and/or ground water contamination is present. do not complete the leadvh'g,pot fat <br /> analysis. (i.e., site is currently an UGT Contamination List for snit or ground wstft►:}/ <br /> \1 If depth is ), 5 ft. and < 25 ft., score 0 points. If depth -CW5 ft., do not use table. <br /> \2 If precipitation is 3- 40 inches, scare 0 points. <br /> \3 Levels far BTXEE are not applicable at a TPH concentration of 10 ppm (gasollne) or 100 ppm (diesel). <br /> fi Vi. STAFF RECOMMENDATION/CONCLUSION n <br /> 1. Are BTX A E Or TPN Concentrations > Allowable Levels *Yes No <br /> 2. Recommend Site Closure Yes Ne If Yes, Refer to Site Mitigation for Evaluation <br /> V1I. REVIEW EVALUATION - To BE COMPLETED ST A SUPERYI SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES V NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED / / <br /> NAME OF <br /> EVALUATOR <br /> { EH 23 80 (UGTWKSHT)\5/90 <br />