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SAN JaAQUIHdWkh1X PUBLIC HEALTH SERVICES/ENVIRONMENTAL H VISION <br /> i. WORKSHEET FOR SITE CLOSURE EVALUATION IM OATEI %_ 2 <br /> NAME OF FACILITY SWEEPS CODE( �93 <br /> ADDRESS " TANK ID <br /> TANK SIZE( (FUEL TYPE <br /> 1I. GENERAL SITE HISTORY <br /> Is permit current? Yes No Permit 9 - Facility Status CadeDoc.SoiL/GW Cont Yes No <br /> Nunber of Tanks at facility Age of Tanks(if available) Type of Tank ISteel FbrgL ISngL Dual <br /> III. TANK HISTORY <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 IIf yes, what was repaired? P,- �Se .—fe 5'f- <br /> Was repair done under inspection?i Yes No Were soil samples analyzed? Yes No BTXE (TPH-G TAH-D Pb/EDB <br /> Type of failure/discharge catastrophic Ilong-term leakage overfill (unknown I other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE OETAILS/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 WeLL(S) Yes No Number & Type Irr Dan pub <br /> S Score S Score S Score <br /> Distance to Wetl(s) 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 Potential Analysis E is met _ is met E is met <br /> Minimun Depth to groundwater from the Soil Sample (feet) >100 I 51-100 125-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) I None Unknown I (Present <br /> Average Annuat Precipitation (inches) xxxxxxj 00 9 110-25 Ixxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) None ( Unknown I Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. I At least More than <br /> xxxxxxl None one one <br /> COLUMN TOTALS»>TOTAL POINTS + + I <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more I 41 - 48 pts I 40 pts or Less <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1rsTo 50I 50 .3 I.3 1. 1. NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE 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 /> 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 c=5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > AllowableLevels *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 SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES) INOI (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 />