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SAN JOAOU.&LINTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H DIVISION <br /> I, UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> DATE %_fi 4 — <br /> NAME OF FACILITY I /7 ` S �� - ISWEEPS CODE( �Lf• <br /> ADDRESS I ✓, l ANK ID :I � ! 16 G 4f — <br /> TANK SIZE( �f1L) IFUEL TYPGI <br /> 11. G-c14ERAL S:TE HISTORY <br /> is permit current?IYesI No Permit �I - (Facility Status Code) Doc.SciL/GW Cont Yes INoI <br /> Number of Tanks at facility) Age of Tanks(if available) I.Type of Tank Steel FbrgL ISngII Duall <br /> III. TANK HISTORY <br /> Was lank tested? Yes) INoI (Failed precision test ?IYesI INoI If yes, give date(s)I <br /> Was a repair made to the tank system?+Yes) NoI If yes, what was repaired?( <br /> Was repair done under inspection?IYes I INoI Were soil samples analyzed?IYesI INoI BTXEI (TPH-GI TPH-01 Pb/EDB( <br /> Type of failure/discharge) (catastrophic long-term Leakage) )overfill) (unknown, (other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samoles Received IYes INoI Depth to Ground Water) IRef/Year1 (Average Annual Precipitation lA=114 10-25 <br /> On-Site Well(s) Yesl INoI INumber & Typel IIrr1 IDomI IPuoI <br /> S (Score S Score s ,Score <br /> Distance to Wells) from lank ft; ft; ft C 10 pts C 9 pts C 15 pts <br /> 0 if 0 if 0 it <br /> R condition R condition R condition <br /> IV. Site Feature - Leaching Potential Analysis ) -- l� _ E is met = is met lis met <br /> !Minimum Depth to groundwater ,from the Soil Sample (feet) I I >100 I 151-100 I U 125-50\1 <br /> (Fractures in subsurface (applies to foothills or mountain areas) lj ;� I None I I Unknown I (Present <br /> (Average Annual Precipitation (inches) Ixxxxxxl <10 9 110-25 Ixxxxxxxl Z5-40\Z <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) ? l) 1 None ` Unknown Present <br /> (Unique site features: Recharge area, coarse soil, nearby wells. I one <br /> I At least) )More than <br /> sxXXXXI None one <br /> COLUMN TOTALS»>TOTAL POINTSrr .a - l <br /> - Result. (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts!f 40 pts or less <br /> Sample 1.\ <br /> A I PI) MAXIMUM ALLOWABLE 3-T-X-E LEVELS (PPM) 11 50I 50I 5D I ..3 I.3 11. 1. I NA\3 <br /> Sample Result:,',l �� GASOLINE 1000 I 100 l 10 <br /> !! MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH DIESEL 1 10,000 I 1000 100 <br /> FOOTNOTES: """If documented soil and/or ground water contamination is present, do not complete the-teaclxia a tial <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 TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels I"Yesl INoI / �7r✓ � �" '� �- <br /> 2. Recommend Site Closure Yes INo L-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 CLOSUREIYESI INOI (REFERRED TO SITE MITIGATION FOR EVALUATIONIYESI IN01 <br /> DATE REF-cRREDI (DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />