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SAN d0A0UI! - 'U.TY PUBLIC HEALTH SERVICES/E4VIRONMENTAL H "..DIVISION <br /> I, ;T WORKSHEET FOR SITE CLOSURE EVALUATION DATE; <br /> NAME OF FACILITY , fJ C +SWEEPS CODE <br /> ADDRESSI C),b 11 ?7 �� C YU (TANK ID l_39 <br /> TANK SIZE! j1 ) (FUEL TYPE 17 <br /> I[. GENERAL SITES HISTORY <br /> is permit current? Yesl No Permir #1 Facility Status Coder_q 1Doc.Soil/GW Cant Yes IN01 <br /> (Number of Tanks at facility (Age of Tanks(if available)( a Type of Tanklsteell Fbrgll ISngl JXDuaL <br /> I I � <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision rest ?1Yes 1140 11f yes, give dares) <br /> Was a repair made to the tank system?IYesi Nol IIf yes, what was repaired? <br /> Was repair done under inspection? Yes No Were soil samples analyzed?lYesl INol BTX E ITPH-G� ITPH-D 1Pb/EDB I 1 <br /> iType of faiture/dischar'ge catastrophicl (long-term leakage overfill unknownl lother: i <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples ReceivedYesl Na Depth to Ground Water{ a (Ref/Year1l&6 ; Average Annual Precipitation A=114 110 -25 ll <br />' On-Site Wells) Yes !No Number & iype Irr (Dom Pub I t <br /> S Score S Scare S Score � <br /> Distance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R candition R condition R condition <br /> V. Site Feature Leaching Potential Analysis E is met is met E is met <br /> i <br /> (Minimum Depth to groundwater from the Soil Sample (feet)so.—/4q, 1 >100 i 151-100 j 1 25-50\1 <br /> subsurface (applies to toothilts or mountain areas) None "' ' •' _:_ <br /> (Fractures In subs pp - 7` I Unknown I Present <br /> L✓ <br /> Average Annual Precipitation (inches) xxzxxxl <10 I 9 10-25 ixxxxxxxl 25-40\2 <br /> (fan-Made conduits. which increase vertical migration i <br /> of leachate (i.e., septic systems, water wells, ponds) None { Unknown (Present P <br /> Unique site features: Recharge area, coarse soil, nearby wells. At Least More than <br /> xxxx�xx None q ' ane on'e <br /> COLUMN TOTALS»>TOTAL POINTS ( Lf + 3 1 + ! (1 .3 6 <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49:prs or more I 41 48 pts ptsor e <br /> I-{2, L-e,st, ND <br /> 7 H a, r�S"r:. tub a T x E s JT X E <br /> MAXIMUM ALLOWABLE a T-x-E LEVELS (PPM) 1 50 50! 50 .3 .3 1. 1. NA\3 <br /> Sample Result: _ jaASOLINE 1GD0 100 10 <br /> _I W @ 5 MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> K _ 4 TPH ff DIESEL 10,00D 1000 100 1 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete th leaching potential <br /> analysis. (i.e., site is currently an UGT Contamination List for soil or ground water.) <br /> \1 if depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. G <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTX&E are not applicable at a TPH concentration of ID ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLU5ION EAs fi <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels I*Yes INo( I L , ,/r• <br /> 2. Recommend Site Closure Yes No *If Yes, Refer to site Mitigation for Evaluation <br /> i <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> 3 <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES( INOI iREFERRED TO SITE MITIGATION FOR EVALUATIONIYESI IHOI 1 <br /> DATE REFERRED / / DATE CLOSURE LETTER :WILED <br /> I s <br /> NAME OF <br /> EVALUATORI <br /> EH 23 30 (UGTWKSHT)\5/90 <br />