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SAN JOAVAJIN -Y PUBLIC HEALTH SERVICES/ENVIROMMENTAL HE 11VISION <br /> 1. WORKSHEET FOR SITE CLOSURE EVALUATION DATE ' <br /> NAME OF FACILITY fiS�E COO E <br /> ADDRESS ! ; 1 TANK ID 0 - f �«- <br /> TANK SIZE FUEL TYPzc <br /> E <br /> 11. GENERAL SITE HISTORY <br /> is permit current? Yes No Permit Facility Status Code Doc.Soil/GW Cont Yes No <br /> Number of Tanks at facility Age of Tanks(if available) Type of Tank�St l Fbrgl Sngl Dual <br /> III. TANK HISTORY <br /> Was Tank test Yes No Failed precision test ? Yes No If yes, give dates) <br /> Was a repair made to the tank systmV Yes No �If yes, what was repaired? <br /> Was repair done under inspection?i Yes No Were soil samples analyzed? Yes No BTXE TPH-G TPN-0 Pb/EDB <br /> Type of failure/discharge catastrophic tong-term leakage overfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIALANALYSIS) <br /> Sail Samples Received Yes No Depth to Gro Water f( Ref/Year Average t Precipitation A= 14 10-25 <br /> On-Site Welts) Yes No Number & Type Irr Dom Pub <br /> S Score S Score S Score <br /> Distance to Wells) frau 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 E is ret E is met <br /> Minimum Depth to groundwater frau the Soil Sample (feet) >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) None Unknown Present <br /> Unique site features; Recharge area, coarse soil, nearby wells. At least More than <br /> xxxxxx None one one <br /> COLUMN TOTALS—TOTAL POINTS <br /> Sade Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 4a pts 40 pts or less <br /> B T X E S T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 SQ 50f SQ .3 .3 1. 1. NA\3 <br /> Sample Result; GASOLINE 1000 100 10 <br /> INUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH DIESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil 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., 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 /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPM Concentrations > Allowable Levels *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 YESI 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 />