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RONMENTAL <br /> SAN JOAOUA..i-OUGST WORKSXEETAFOR SITE CLOSUREI EVALUATI Ol1� LTH DIVISION <br /> 1.NAME OF FACILITY # DATE <br /> SWEEPS CODE <br /> �-7 <br /> 1 TANK ID­#j <br /> ADDRESS <br /> TANK SIZE I FUEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> is permit current? Yes No Permit # - Facility Status Code DCC.SOiI/GW Cant Yes No <br /> Number of Tanks at facility <br /> Age of Tanks(if available) Type of Tank Steel Fhrgl Sngl Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test ? Yes No [f yes, give date(s) / / / / <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? <br /> Was repair done under inspection? Yes No Were soil samples analyzed? Yes No BTXE TPH-G TPH-D Pb/ED8 <br /> Type of failure/discharge catastrophic Long-term leakage overfill unknown ocher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Ground Water Ret/Year <br /> Average Annual Precipitation A= 14 10.25 <br /> On-Site Wells) Yes No Number 8 Type Irr Dom Pub <br /> S Score S Score S Score <br /> Distance to Wells) from 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 met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet) <br /> >100 51-100 25-50\1 <br /> Hone Unknown Present <br /> Fractures in subsurface (applies to foothills or mountain areas) 1 <br /> Average Annual Precipitation (inches) <br /> zxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration None q Unknown Present <br /> of leachate (i.e., septic systems, water wells, ponds) <br /> At leas! More than <br /> Unique site features: Recharge area, coarse soil, nearby wells. xxxxxx None one one <br /> SSampCOLUMN TOTALS»>TOTAL POINTS <br /> 415- <br /> Sample <br /> le Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> 0 T e. B T X E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> GASOLINE 1000 100 10 <br /> Sample Result: MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> DIESEL 10,000 1000 100 <br /> _TPH <br /> FOOTNOTES: ***If documented soil and/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 BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX b E or TPH Concentrati > 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/S IOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CL SURE YES NO 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 />