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SAN JOA4. d`+ .ITY PUBLIC HEALTH SERVICES/ENVIRONMENTAL i DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY <br /> SWEEPS CODE <br /> v`1 <br /> ADDRESS p TANK ID <br /> TANK SIZE 1060 1 FUEL TYPE d <br /> II. GENERAL SI E HISTORY <br /> Is permit current? Yes INo Permit - FaciLity Status cc.Sail/Gini Cant Yes No <br /> Number of Tanks at facility �t Age of Tanks(if availab e)I �IType of Tank Steel Fbrgi ISng! Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test ? Yes <br /> uas a repair made to the tank system? Yes No If yes, what as repaired? <br /> Was repair done under inspection? Yes No Were sail samples analyzed?1Yes No STXE TPH-G TPH-D Pb/EDB <br /> Type of failure/discharge) (catastrophic Long-term leakage overfilll (unknown other; <br /> IV. REMOVAL HISTORY (ATTACH INSPEECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Sail Samples Received Yes No IDepth to Ground Water 5 Ref Year /45 Average Annua! Precipitation A= 16 10-25 <br /> On-SiteUell(s) Yes NoI Number L Type Irr (Dom Ip <br /> S score S Score S Score <br /> Distance to Wells) from Tankl 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 E is met E is met <br /> Minimum Depth to groundwater frac the SoiL Sample (feet) >100 I I51-100 I z5-sa\1 <br /> (Fractures in subsurface (aapties to foothills or mountain areas) I None G� Unknown (Present <br /> Average Annual Precipitation (inches) xxxxxxi <10 9 110-25( 26-40\2z <br /> Mart-Made conduits which increase vertical migration i <br /> or Leachate (i.e., septic systems, water wells, ponds) I None Unknawn Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> xxxxxx None ane one I <br /> COLUMN TOTALS?»TOTAL POINTS <br /> 5 mpte Result: (B T X OR E) RANGE OF TOTAL Poi TS 49 pts or more 41 - 48 pts <br /> p40 pts or less <br /> .Rey <br /> MAXIMUM ALLOWABLE a-T-X-E LEVELS (PP, <br /> P ) 8� 50I 50 50 .3 I <br /> .3 � 1. �_ � NA\3 <br /> S_m Rem PP"ri GASOLINE 1000 100 10 <br /> 1�'�� MAXIMUM ALLOWABLE TPH LEVELS CPPN) <br /> 2RISwnTPWJ) D[ESEL 10,000 1000 1D0 <br /> FOOTNOTES: ***If documented sail and/or ground water contamination is present, do not complete the leaching poteni:iat <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., scare 0 points if depth =5 ft-, do not use tabie. <br /> \2 If precipitation is > 40 inches, scare 0 points. <br /> \3 Levels for M&E are not applicable at a TPH c tration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are 8TX & E or TPH Concentrations > Allowable Levels *Yes No <br /> 2. Recommend Site CLasure Yesl No I X�_lf Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED ArY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE:YES( Nor I REFERRED TO SITE MITIGATION FOR EVALUATIONIYES 1N0 <br /> DATE REFERRED / / DATE CLOSURE LETTER NAILED) <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWK5HT)\5/90 <br />