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SAN JOAOU. COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL __LTH OIVISION, <br /> I• UGST WORKSHEET FOR SITE CLOSURE EVALUATION- I DATE <br /> NAME OF FACILITY ° ','- - '' SWEEPS CODE <br /> ADDRESSO � �f Y aTANK III - , <br /> U <br /> TANK S I ZE /I Q �� FUEL Gtltc' 't . <br /> II. GENERAL SITE HISTORY <br /> I t <br /> is permit current? Yes No Permit 9 - Facility Status Code Doc_Soil/GW Cont Yes No <br /> Number of Tanks at facility Age of Tanks(if available) Type of Tank Steel .` Fbrgt 5ngl Dual <br /> III. TANK HISTORY I <br /> Was Tank tested? Yes No 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?] <br /> nspectionT Yes No dere soil samples analyzed?I Yes No BTXE E ITPH-G TAH-D Pb/EDB <br /> Type of failure/discharge catastrophic long-term leakage overfill unknown other: J . <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes INo Depth to Ground Waterj,` Ref/Year ; Average Annuat;Precipitation A= 14 .10-25 <br /> Yes No Number & Type irr Dom <br /> ion-Site WeLL(s) Pup } <br /> S Score S Score S Score <br /> Distance to Well(S) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 i4;i 1 0 if <br /> R condition R condition R condition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> Minimum Depth to groundwater from the Sail Sample (feet) I >1Q0 51-.100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) I None Unknown Present <br /> (Average Annual Precipitation (inches) xxxx= <10 9 10-25 xxxxxxx1 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) None Unknown 1Present <br /> Unique site features: Recharge area, coarse sail, nearby wells. At least More than <br /> xxxxx x .None rnie one <br /> I ' <br /> COLUMN TOTALS —TOTAL POINTS + I }« _ - <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts�\ 40 pts or less <br /> 7 2 d D �N111- MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) a 50l 50 50 .3 .3 1.1 1. NA\3 <br /> Sample Result- 4F0 GASOLINE 1000 100 10 <br /> P fJT O TP MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> Ce e Q DIESEL 10,OOD 1000 I i 100 <br /> FOOTNOTES: ***If PQ94nented soil and/or grand w ter contamination is present, 4tnot a teaching potential <br /> analysis. (i.e., site is currently on 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. <br /> \2 If precipitation is > 40 inches, scare 0 points. f <br /> \3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 1013 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION _ <br /> 1. Are 3TX & E or TPH Concentrations > Atlowabte Levels *Yes No T& ✓1f i') <br /> r'7 r �[3c.2.� �T <br /> 2. Recommend Site Closure les No *1f Yes, Refer to site Mitigation for Evaluation <br /> s <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE IYES 1 NOI REFERRED TO SITE MITIGATION FOR EVALUATIONIYE F NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF I i I <br /> EVALUATOR <br /> Eli 23 80 (UGTWKSHT)\5/90 f <br /> I � <br />