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SAH JOAQUi Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL .DIVISION <br /> Ii WORKSHEET FOR SITE CLOSURE EVALUATION ATE . <br /> 36 • Z <br /> AMEOF ACILI �rpQyClrnLSSLOCa SWEEPS CODE <br /> TANK ED # <br /> '1�) <br /> ISO-5 Eqs <br /> ANX SIZE UCO UEL TYPE QQ l q� <br /> 11. GENERAL SITE HISTORY �r <br /> Is permit current7 as o ermit IF <br /> aciIicy Status Code rj oc.Soil/GW C=2 <br /> EDua <br /> umber of Tanks at facility 3 ge of Tanks(if available) UnK ype of Tank reel Fbrgl rgE <br /> Ill. TANK HISTORY <br /> 'as Tank tested? es o ailed precision test ? es o If yes, give dates)T <br /> Jas a repair made to the tank system? Yes No 11f yes, what was repaired? <br /> is repair done under inspection? es No ere soil samples analyzed? es Ie TXE PH-G PH-0 b/EDB <br /> �ype of failure/discharge Datastrophic ea <br /> long-term Lkage verfill nknown Ther: <br /> IV, REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FCR LEACHING POTENTIAL ANALYSIS) <br /> oit Samples Received es o epth to Ground hater of/Year DO"i;a"'n verage Annual Precipitation = 4 10-25 <br /> -Site uelL(s) es o umber & Type Irr cm ub <br /> S Score S Score S core <br /> istance to Well(s) from Tank ft; ft; ft C 10 pts C 9 pts C pts <br /> 0 if0 if 0 f <br /> R ondition R condition R ondition <br /> . Site Feature - Leaching Potential Analysis E is met E is met E �is met <br /> f <br /> inimum Depth to groundwater from the Soil Sample (feet) �'� >100 1.100 25-50\1 <br /> ractureS in subsurface (applies to foothills or mountain areas) None Unknown Dresent <br /> verage Annuat Precipitation (inches) xxxx <10 9 10-25 xxxxxxx 26-4012 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> f. inique site features: Recharge area, coarse soil, nearby wells. At Least lore than <br /> xxxx None one one <br /> COLUMN TOTAL S»>TOTAL POINTS 2 ' J :5 Z <br /> ample Result: (9 T X OR E) RANGE OF TOTALPOINTS 9 pts or more 41 48 pts 40 pts or Less <br /> �- �- x- ago <br /> T- 2t0p-Q6 m MAXIMUM ALLOWABLE B-T-x-f LfYELS 3 <br /> (PPM) 1 55 T0 50 <br /> 50 X E B T X E <br /> .3 1. 1. NA\3 <br /> Sample Result: ASOLINE 1000 100 10 <br /> XIM04 ALLOWABLE TPN LEVELS (PPM) <br /> TPH M IESEL 10,000 1000 100 <br /> i <br /> FOOTNOTES: ***If documented soiL and/or ground water contamination is present, do not craplete 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 <=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 TPN concentration of 10 ppm (gasoline) or.100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION i5l�m <br /> I <br />'r 1. Are 8TX & E or TPH Concentrations > Allowable Levels YesFx <br /> t 2. Rec=nend Site CLosure es o If Yes, Refer to Site Mitigation for Evatuarion <br /> VII, REVIEW EVALUATION - To BE CCNPLETED BY A SUPERVISOR/SENIOR <br /> INCUR WITH STAFF RECOHMENDATIOH FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION :OR EVALUATION ES 0 <br /> ATE REFERRED / �" / ATE CLOSURE LETTER HAILED . <br /> AME OF <br /> .VALUATOR <br /> EH 23 80 (UGTWXSH,1�)\5/90 <br /> ZH 29 80 % <br /> i . <br />