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SAN 4A0UIN / TY PUBLIC HEALTH SERVICS/ENVIRCNMENTAL HEAP DIVISICH <br />I. 1%/ST WORKSHEET FOR SITE CLOSURE EVALUATION GATE <br />NAME OF FACILITY SWEEPS CCOEI 3 <br />1ADORESSI I OV TANK 10 .l <br />(TANK SIZEI (FUEL TYPE[ <br />II. GENERAL SITE HISTORY ��JJ Jrlr r'1 <br />e,r> <br />jfs permit current?Yes No Perini 2 3 - IFacility Status Codel Oac-Sail/CW CdntlYesl NoI <br />,Nu mer of Tanks at facility Age of Tanks(if availaole)I (Type of Tank Steell IFbrgLI ISngLI Ow 1 <br />1 <br />:TI. TANK HISTORY <br />Was Tank tested? <br />Yes <br />INo <br />IFailed precision test <br />?IYes I INaI <br />Ilf yes, give care(s)I / / <br />'':as a repair made to the tank system?I YesI go <br />Iif yes, war was repaired?I <br />Was repair done under inspection? I YesI He Were soil samples analyzed? IYesI INaI <br />BTXEI <br />ITPH-GI ITPR-OI <br />IPb/EDBI I <br />.ype of failure/discharge) Icatastrophicl <br />(long-term leakage) <br />IoverfiI ll <br />IunknatalI <br />Iocher: <br />V. REMOVAL 81STCRY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT OATA FOR LEACHING POTENTIAL ANALYSIS) <br />:Soil Samples Received <br />IYesI <br />NoI Depth to Ground Waterl <br />Ref/Year) <br />1Average Annual precipitation <br />I A=I14 <br />110-251 <br />Cn-Site WeIL(s)IYes I <br />INoI INulber b type) <br />IrrI <br />IDam <br />IPuol <br />S <br />C <br />0 <br />3 <br />_ <br />Scare <br />t0 pts <br />if <br />condition <br />Is met <br />S <br />C <br />0 <br />.R <br />Score <br />9 pts <br />it <br />condition <br />is .met <br />S <br />C <br />I O <br />R <br />Score <br />5 pis <br />if <br />condition <br />is met <br />Distance to Wells) from lank <br />ft; ft; <br />V. SILK Feature - Leaching Potential Analysis <br />Minimum Oepth to groundwater from the Soil Sample (feet) I <br />>100 <br />I i51-100 <br />I 25-50\1 I <br />F-actures in subsurface (applies to foothills or mountain areas) I <br />( Hone <br />I <br />I Unkrrown 1 <br />(Present <br />!Average Annual Precipitation (inches) Ixzzxxxl <br /><10 <br />I 9 <br />110-Z5 Izxx==j <br />26-40\2 <br />Man -Made conduits which increase vertical migration <br />.of leachate (i.e., septic systems, water wells, ponds) <br />None <br />I Unknown <br />Present <br />Biunique site features: Recharge area, coarse soil, nearby wells. <br />IxuzzX <br />Vane <br />At least <br />we <br />More than <br />one <br />COLUMN TOTALS>»TOTAL POINTS <br />Samele Result: (S T X OR <br />Pc X = .� Ab u <br />IJI�C A1i$E= .13 (�f+y <br />9 <br />ZANGEE OF TOTAL POINTS 49 <br />pts or mor_ <br />61 - 'Z pts <br />:0 pts or less <br />MAXI" ALLOWABLE 3 -T -X -E LEVELS (PPM) <br />3 i X E <br />tl i0l i0 i0 <br />3 T X <br />.3 .3 1.I 1- <br />NA\3 <br />Sample Result: GASOLINE <br />Sit ; PH&= a. a mMAXIMLNI ALLOWABLE TPN LEVELS (PPM) <br />TPH DIESEL <br />1000 <br />TOO <br />I 10 <br />10,000 <br />I 1000 <br />I 100 <br />FOOTNOTES: "'tf documented soil and/or ground water contamination is present, do not complete the leaclling potential <br />analysis. (i.e., site is currently an UGT Canewination List for soil or ground water-) <br />\1 If depth is > 5 ft- and < 25 ft., score 0 points. If depth c5 ft., do not use table. <br />\2 If precipitation is > 40 incites, score 0 points - <br />\3 Levels for 3TUE are not applicable at a TPH concentration of TO ppm (gaso(ine) or TOO ppm CdieseU- <br />VI. STAFF REC.CMMENDATION/CONCLUSION <br />1, Are 3TX b E or TPH Cancentratiare > Allowaole Levels 1-Yesl 1NoI <br />?. Recommend Size Cl dsurcl Yesl NoI 1- If Yes, ?afar Co Site Mitigation for 9valuatidn <br />VII. RE'/[EW EVALUATION - TO 3E COMPLETED 3Y A SUPERVISOR/SEHICR <br />COHCJR WITH STAFF RECC:MLE.NOATICN FOR CLOSLREjYEsj INOI IREFERREO TO SITE 9ITIGATION FOR E/ALJATIONI YES( INOI I I <br />DATE REFERRED / / (DATE CLOSURE LETTER MAILED( <br />NAME OF <br />E'/ALUATOR <br />EH 33 30 (UGTWKSHT)\5/90 <br />