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SAN JOAOUI) 'LINTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL ' TH DIVISION <br /> I• JGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE 1) <br /> NAME OF FACILITY 1> .--I K. i _ �� � ._ > > SWEEPS CODE <br /> ADDRESS 7� ( I— TANK ID 0 - <br /> TANK SIZE 5 FUEL TYPE /U <br /> Il. GENERAL SITE HISTORY <br /> Is permit current? Yes / No Permit % - FaciLity Status Code Doc.Sail/GW Cant Yes No <br /> Number of Tanks at facility / Age of Tanks0 f available) Type of Tank Steel 'X Fbrgl Sngl Dual <br /> 111. TANK HISTORY <br /> was Tank tested? Yes No x Failed precision test ? Yes Na If yes, give date(s) <br /> Was a repair made to the tank system? Yes No if yes, what was repaired?I <br /> Was repair done under inspection? Yes NoI Were sail samples analyzed? Yes No BTXE TPH-GI TPH-O Pb/EDB <br /> Type of failure/discharge) catastrophic Lang-term leakage overfill I unknown I other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes Na Depth to Ground Water Ref/Year Average Annual Precipitation A= 14 10-25 <br /> On-Site Welt(s) Yes No (Number & Type Irr Dam Pub <br /> S Score 5 Tc,�dinll <br /> Score <br /> Distance to Wells) frau Tank ft; ft; ft C 10 pts C 5 pts <br /> 0 if 0 if <br /> R candi ti on R condition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met <br /> Minimum Depth to groundwater from the SoiL Sample (feet) I >100 9 51-100 125-50\1 <br /> Fractures in subsurface (applies to foothiLLs or mountain areas) 10 None I Unknown I (Present <br /> (Average Annual Precipitation (inches) xxxxxxl <10 I 9 1 10-257 xxxxxxxl 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) None q Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby weLLs. At Least More than <br /> =Xxx None 4 one one <br /> 36 I <br /> COLUMN 70TALS>)>TOTAL POINTS �Q I + E <br /> S'Mi uT (9)(x 0;% RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or Less <br /> p`{ n)D NO 0 OM AID B T XE B T X E <br /> 0.a71 042 S.3 0,5Z MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 SD 50 I .3 .3 1. 1. NA\3 <br /> (Sample Result: GASOLINE 1000 100 10 <br /> IP{. -MNQ NI> TPKD Nb IMAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> .9P TAIQ `tel TP10 k DIESEL 70,000 7000 100 <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 < ZS 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 M&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (dieser)). <br /> VI. STAFF RECOMMENDATION/CONCLUSION �C-1-w' g -V K•(.-Lrh e <br /> 1. Are BTX & E or TPH Concentrations > Alllow�able Levels -Yes No kPRID (0000 �^+ <br /> 2. Recommend Site ClosureI Yes) (NoI �'If Yes, Refer to Site Mitigation for Evaluation 14a o1_rz Lc� <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR V <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSUREIYES1 NO REFERRED TO SITE MITIGATION FOR EVALUATION I YES INO <br /> DATE REFERRED / / (DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />