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SAN 1`(AGUIN —X—, PUBLIC HEALTH SERVICES/ENVIRCNMENTAL HF"TH DIVISION <br /> I. SST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> NAME OF FACILITY /J// "7 / / _ T SWEEPS CODE( <br /> ADDRESS <br /> TANK SIZE 1 M4 FUEL TYPE <br /> II. GENERAL Si E HISTOR7 <br /> Is permit current? Yes No (Permit S - (Facility Status Code IDoc.Soil/GW Cont Yes' Nol <br /> Nurber of Tanks at facitity Ape of Tanks(if available) Type of Tank St"L br l�FDuat <br /> III. TANK HISTORY <br /> Was Tank tested? Yes \ NoI Failed precision test 7 Y"I No If 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 inspectiont Yes IbI 1wert soil samples anaLyzedt Yet No BTXEI TPH-G TPH-OI IPbMilB <br /> Type of failure/discharge) catastrophic) hang-term Leakage overfill unk:noal other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DET L$/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) F Ey <br /> Soil Samples Received Yes No Depth to ;round Wt r Ref/Year Average Annual Precipitation A-I14 10-25 <br /> On-Site WeLL(s) Yes No INumber t Type Irrl Dom iPub <br /> $ Scam S Score 5 Score <br /> Distance to WeLL(s) 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 condi ti an R icondition <br /> V. Site Feature - Leaching Potential Analysis E is net E is met E is met <br /> Minim= Depth to grotrdvater from the Soil Sample (feet) 0 >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None I Unknown I (Present <br /> Average Annual Precipitation (inches) z:ocmc <10 9 10-25 1=00=1 25-40\2 <br /> Man-Made conduits which increase vertical agration <br /> of leachate (i.e., septic systems, voter reals, ponds) xana Lkiknown Present <br /> Unique site features-. Recharge area, coarse soi L, nearby wells. At LeastMore than <br /> )R:OLt1t None one ane <br /> COLUMN TOTALS»TOTAL POINTS + + <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 4a pts 40 Pts or Less <br /> gam., oar' No <br /> E=: O�O�S__ AIDtA a 7 X E B T Y <br /> eewr �.�6o MAXI)RR( ALLOWABLE g-T-X-E LEVELS (PPM) 1 50I 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: GASOLINE 1000 100 I 10 <br /> MAXIMUM ALLOWABLE TPH L_sVELS (DPM) <br /> DIESEL 10,000 1000 100 <br /> FOOTNOTES: —If doa=ented soil and/or ground eater eontaminatim is present, do not coaplete the Leaching potential <br /> analysis. (i.e., site is currently on UGT Cmtamination List for soil or ground rater.) <br /> \1 If depth is > 5 ft. an: < 25 ft., scare 0 points. If depth o5 ft., do not use table. <br /> \Z if precipitatim is > 4 inch", score 0 points. <br /> \3 Levels for STXLE are nst applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (dilmel). <br /> V1. <br /> STAFF RECOMPTIDATION/CONCLUSION <br /> 1. An BTX b E or TPH Concmtrativs > ALLoweble Levels IeT"I No <br /> I <br /> 2. Recommed Site CLosurelyes A No L�-If Y", Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED By A SUPERVISCR/SEXICR <br /> CONCUR WITH STAFF RECCMMENDATICN FOR CLLS.YE I YESI NOI IREFERRED TO SITE MITIGATION FOR EVALUATION YES (EDI <br /> DATE REF-ERRED / / (DATE CLOSURE LETTER MAILED( <br /> NAME OF <br /> EVALUATOR <br /> EH 23 30 (UG7WKSHT)\5/90 <br />