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SAN JOAQUINTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H# DIVISION n b <br /> I. ,ST WORKSHEET FOR SITE CLOSURE EVALUATION DATE � <br /> NAME OF FACILITY bG CQ.IL ��I� SWEEPS CODE <br /> ADDRESS 6q S V�V TANK ID # -05o -7867TANK SIZE d 2 O FUEL TYPE <br /> 11. GENERAL SITE HISTORY *f* <br /> Is perEof <br /> urrent? Yes IK No Permit # Facility Status Code Doc.Soil/GW Cant Yes No <br /> Numberanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl SngL Dual <br /> II1. TANK HISTORY C31 t <br /> EWas tested? Yes No Failed precision test ? Yes 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 inspection? Yes TLoTng-t7ermtea7ka9eNoverfi <br /> Mttutnknownnother: <br /> BTXE TPH I TPH-D Pb/EDB <br /> Type of failure/discharge catastrophic <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 Ref/Year Average Annual Precipitation A= 14 10 25 <br /> On Site WeLt(s) Yes No Number & Type Irr Dom Pub <br /> S Score S Score S Scare <br /> Distance to WeLL(s) from Tank ft; ft; ft C r 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 /> Minimun Depth to groundwater from the Sail Sample (feet) >100 `97 51-100 25-50\1 <br /> Fractures in subsurface (applies to feothills or mountain areas) None (�� Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration None 5;71 Unknown Present <br /> of leachate (i.e., septic systems, water wells, ponds) <br /> Unique site features: Recharge area, coarse soil, nearby wells. At Least More than <br /> xxxxxx None one one <br /> COLUMN TOTALS}»TOTAL POINTS + � + <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 48 pts 40 pts or less <br /> t }� B TX E 6 JT X E <br /> h] hJ MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 SO .3 .3 1. 1. NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH b DIESEL 10,Do 1000 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 < 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 *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/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION TES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED / <br /> NAME OF <br /> EVALUATOR <br /> I 9-,U� <br /> EH 23 80 (UGTWKSHT)\5/90 <br />