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SAN .IOAQUIr COUNTY PUBLIC HEALTH SERVICES/ExY1RUMXTAL HEALTH 0IYI5[ar1 <br /> WORKSHEET FOR SITE CLOSURE EVALUATION 1 GATE <br /> NAME OF FACILITY :tm 3 lilt 0 <br /> 'iPS�CODE <br /> T!"��l-Ch I N <br /> ADDRESS ! �' $�$ L n c e e J C-4 TA"K S-4t,do 4:( W 4- <br /> TANK SIZE 10,00 O FUEL TYPE Lew <br /> II. GENERAL SITE HISTORY <br /> Is permit current? Yes No Permit N - Facility Status Code Dao.Soil/GV Cont Yes No <br /> ,i <br /> Number of Tanks at facility Agt of Tanks(if available) Type of Tank Steel 4misl SnglI. Dual <br /> Iii. TANK HISTORY <br /> Was Tank tested? Yea No Failed precisions test ?:Yea No tf yes, give dete(s) <br /> Was a repair made to the tank system? Yes NoIf yes. what was repaired? <br /> was repair done under inspection? Yes No I/were soil samples analyzed? Yes No BTXE TPH-G TPH-0 WEDS <br /> Type of failure/discharge catastrophic long-term leakage overfill unkno+as other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTI.ON REPORT FOR SITE.DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Sail Samples Received Yes No Depth to Ground Water 3l7� Ref/Year y Average Annual Precipitation 7if <br /> On-Site Wells) Yes No Nunber i Type Irr Liam PubS Score S Score S Distance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C 0 if 0 if 0 <br /> R condition R condition R condition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E. is met <br />" Minimus Depth to groundwater from the Soil Sa4ple (feet) 3� >100 - 0 51-100 25-50\S <br /> Fractures in subsurface (applies to foothills:�or mountain areas) None Unknown Present <br /> EAverage Annual Precipitation (inches) xxxxxx. <10 9 10-25 xxxzxxx 26.40\2 <br /> Ilan-Made conduits which increase vertical migration <br /> of leachate (i-e., septic systems, water welts, ponds) None Unknown Present <br /> Unique site features: Recharge area, coarse soil, .nearby walls. At least More than <br /> xxxxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pis "` •rs '} <br /> 7�.3EF_ ,Z 0 T X E T X E <br /> MAXIMUM ALLOWBLE B-T-:X-E LEVELS (PPM) 1 50 50 50 .3. 1 NA\3 <br /> Sample Result: GASOLINE 1000 - <br /> MAXIMUR ALLOWBLE .TAH LEVELS (PPM) <br /> -31- TPI- 000 100 <br /> FOOTNOTES: ***If documented soil and/or grouts aching pot <br /> water contamination is present, :do rot complete.the teential <br /> analysis. ct.e.; site is currently an UCT Contamination List for soil or grouted water.) <br /> \1 if depth is > 5 ft. and s 25 ft., scare 0 points. If depth a$ ft., dO not use table. <br /> \2 if precipitation is > 40 incises, scare d points. <br /> \3 Levels for BTX&E are not applicable at a TAN concentration of 10 ppcs (gasoline) or 100 ppm (diesel). <br /> Vt. STAFF RECOMMENDATION/CONCLUSION "t k 116 (,(J Q7&+-), <br /> P scow= C <br /> 1. Are BTX L E or TP4 Concentrations > All le LmLs= M0 <br /> 2. Recammlend Site ClosureYea Ma If 'tet, Refer to Site Mitigation for Evaluation �� �Q G(u;,�q�D� <br /> VIZ. REVIEW EVALUATION - TO 8E COMPLETED ST A SUPERVI SENIOR sea shag ,e/u Ma wwd V(,r��� <br /> 56 <br /> CONCUR WITH STAFF RECOMMENDATION FOR CL05URE YES MO REFERRED TO SITE MITIGATION FOR EVALUATION YES Nd <br /> DATE REFERRED / / DATE CL0StJR6 LETTER MAIL® / / <br /> NAME OF <br />{, EVALUATOR <br /> EH Z3 80 (U MSHMa <br /> o <br />,� �... ..MM <br />