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SAN JOAGU LINTY PUBLIC HEALTH SERVICES/ENVIRONMENTALLTH DIVISION <br /> I. (%wUGST WORKSHEET FOR SITE CLOSURE EVALUATIOIe`-' DATE C3—1;7- <br /> Q <br /> NAME OF FACILITY SWEEPS CODE / <br /> ADDRESS o <br /> TANK ID # <br /> TANK SIZE FUEL TYPE O <br /> II. GENERAL SITE HISTORY - �/ <br /> Is permit current? Yes No Permit # - Facility Status Code Doe.Soii/GV Cant Yes No <br /> Number of Tanks at facility Age of Tanks(If available) Type of Tank Steel FbrgL St <br /> Dual <br /> III. TANK HISTORY <br /> Was Tank tested? YesNa Failed precision test 7 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? Yes Na Were soil swiptes analyzed? Yes Na BTXE TPH-G TPH-D pb/EDB <br /> Type of failure/discharge catastrophici term Leakage over unknown 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 Vater D Ref/Year �CP ; Average Annual Precipitation A=114 10-25 <br /> On-Site WellCs) Yes No Number I: Type Irr Dan Pub <br /> S Scare 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 condition R condition R condition <br /> V. Site Feature - Leaching Potentia! Analysis E is met E is met E is met' <br /> Minimum Depth to groundwater frac the Soil Sample (feet) >100 51-100 S 25.50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown Present <br /> Average Arowa! Precipitation Cinches) x a= <10 9 10-Z5 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water swells, ponds) None Unkrum Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> xxxxxx None one one <br /> i <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 /> a t+C = 1UD <br /> 81 X E B T XE <br /> 13 MAXIMUM ALLOWABLE B-T-X-E LEVELS (PAM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: p GASOLINE 1000 100 10 <br /> SPto;t):3,�f fD D MAXIMUM ALLOWABLE TPH LEVELS (PPM) DIESEL t0,000 1000 1Q0 <br /> FOOTNOTES: ***If docua*nted sail and/or ground water contamination is present, do not complete the leaching 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., store 0 points. If depth ­-5 ft., do not use table. <br /> \2 If precipitation is r 40 inches, score 0 points. <br /> \3 Levels for STXSE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF 3ECOMMENDATiON/CONCLUSION e Isl S <br /> 1. Are BTX $ E or TPH Concentrations > Allowable Levels *Yes ., INC IS' o <br /> 2. Recommend Site Closure Yes No If Yes, Refer to Site ?litigation for Evaluation <br /> VII. REVIEW EVALUATION - TO SE COMPLETED BY A SUPERVISOR/ IOR �/ytp�� CCljjllC !! �La <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION TES <br /> DATE REFERRED / / DATE CLOSURE LETTER. MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />