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''JJi <br /> SAN JOAO6IN C PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE/ DIVISION <br /> WORKSHEET FOR SITE CLCZURE EVALUATION DATE <br /> NAME OF FACILITY SWEEPS CODE <br /> ADDRESS TANK ID # - <br /> TANK SIZE FUEL TYPE <br /> II. GENERAL SITE HISTORY <br /> *** <br /> Is permit current? Yes No Permit # - Facility Status Code Doc.Soil/GW Cont Yes No <br /> Number of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No Fai ed precision test 7 Yes No If yes, give date(s) <br /> Was a repair made to the tank syst ? Yes No If yes, what was repaired? <br /> Was repair done under inspection? Y s No Were soil samples analyzed? Yes No BTXE TPH-G TPH-O Pb/EDB <br /> Type of failure/discharge catast ophic long-term leakage overfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTIO REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Ground Water Ref/Year Average Annual Precipitation A= 14 10-25 <br /> On-Site Wells) Yes ±Tank <br /> Number 14 Type Irr Dam Pub <br /> S Score S Score S Score <br /> Distance to WeII(s) from 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 Potenti l Analysis E is met E is met E is met <br /> Minimum Depth to groundwater from tie Soil Sample (feet) >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown Present <br /> Average Annual Precipitation (inche ) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, ater wells, ponds) None Unknown Present <br /> Unique site features: Recharge ar a, coarse soil, nearby wells. 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 pts 40 pts or less <br /> B TX E B JT X E <br /> IMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> MAXIMUM LLOWABLE TPH LEVELS (PPM) <br /> TPH DIESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the leaching potential <br /> analysi (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> \1 If depth is > ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> \2 If precipitati is > 40 inches, score 0 points. <br /> \3 Levels for STX�E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAF= RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPH Concentrat ons > Allowable Levels *Yes No <br /> 2. Recommend Site Closure Yes No If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISCR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION OR CLOSURE YES 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 />