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SAN JCACUIN )ELIC HEALTH SERVICEMEHVIRONMENTAL NEi BION <br /> I �ORKSHEET FOR SITE CLOSURE EVALUATION err GATE) 7-3 <br /> INAME OF FACILITY I /VtCt �. L J(` C<_ ISWE2.'S CCOEI A3 / 6 S <br /> IADORESSI p �� ��.0 A ��ITANY. <br /> (TANK SIZE( �� � (FUEL TYPE! jn4 C � (�, G� 1 <br /> II. GENERAL SITE HISTORY / jlfil1 <br /> :Is permit current?`Yes INoI `Permit 31 - (Facility Status Code d�-IDcc.Scil/GW Cant YesI No <br /> Number of Tanks at facility) / 3 (Age of Tanks(if avaitable)l;3�(" (Type of TanklSteeL XlFbrgll 1Sngll Ouall <br /> I I. TANK HISTORY Y�'�� Cl �— <br /> Was Tank tested? Yes Nol Failed precision test ?`Yes 1Noi IIf yes, give date(s) <br /> ',:as a repair made to the tank systemh?IYes No If yes, what was repaired7l <br /> ;as repair done under inspection?IYes I 1Hoi `Were soil samples analyzed7IYesI 1Nol BTXE1 1TPH-G TPH-01 Pb/E081 <br /> 'ype of failure/discharge` catastrophic) `long-term leakage` Ioverfill I `unknown` (other: <br /> TV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE OETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> ;Soil Samples Received Yes No (Depth to Ground Vater (Ref/Year` `Average Annual precipitation IA=114 110-25 <br /> ICn-Site Wetl(s)IYes l 1No `Number & Typel 71rrl 10om 1Pub j <br /> S Scare S Scars S Scare <br /> !Oiszance to Wetl(s) from Tankl ft; ft; ft C10 pts C 9 pts C 5 pts <br /> 0 if O if 0 if <br /> condition 2 condition R condition <br /> IV. Site Feature - Leaching Potential Analysis _ is net E is ret E is met <br /> (Minimum Oepth to groundwater from the Soil Sade (feet):;i► o - I i >100 I I51-100 I 125-50\1 <br /> 1F-3ctures in subsurface (applies to foothills or ,mountain areas) I Hone I I Unknown I (Present <br /> ]average Annual Precipitation (inches) lxxxxxxl <10 I 9 i 10-25 Ixxxxxxxl 25-40\2 1 <br /> 'Man-?fade conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) I None I i Unknown I � (Present <br /> Unique size features: Recharge area, coarse soil, nearby wells_ I n I At least More than <br /> i <br /> I=,= None �� one one <br /> i <br /> COLUMN TOTALS»>TOTAL POINTS jjDj <br /> i2� <br /> Sale Result• (3 T X OR E) RANGEOF TOTAL POINTS 49 pts or more 41 - 48 pts less <br /> mp <br /> IJ x � � MAXIMUM ALLOWABLE 3-T-X-E LEVELS (PPM) 11 <br /> 50' 50I 50 I .3 I. I 3 t.i 1 I NA\3 <br /> S le Resn}u Lt: _m x/{50/ Me, GASOLINE 1000 I 100 1 10 <br /> = S`V PP MAXIMUM ALLOWABLE TPH LEVELS (PAN) <br /> ) TPH OIESc'L 10,000 l 1000 l 100 <br /> r. TNOTES: —If documented soil and/or ground water contamination is present, do not complete the g po <br /> �VI O`k,� , analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> h } this > 5 ft. and < 25 ft., scare 0 points. if depth <=5 ft., do not use table. <br /> ,n <br /> I�z +��$�68FN� �Z'If precipitation is > 40 inches, score 0 points_ <br /> \3 Levels for 3TX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 1100 ppm (diesel). <br /> VI. STAFF RECCMMENDATION/COHCLUSICH p r�5 e UtJ M rJ3 <br /> 1. Are 3TX & E or TPH Concentrations > Allowable levels "Yes IX <br /> No <br /> 2. Recommend Site Closure lYes l Ime I-If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW _VALUATION - TO 3E COMPLETED 3Y A SUPERVISOR/SENICR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSUREIYESI SOI (REFERRED TO SITE MITIGATION FOR EVALUATIONIYESI �OI l <br /> DATE REFERRED � / / IDATEYCLOSURE L_°TTER MAILPDI <br /> i <br /> NAME OF <br /> EVALUATOR <br /> i <br /> EH 23 80 (UGTWKSHT)\5/90 <br />