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SAN JOAQUINY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA�IVISION <br /> 1. ST WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY �- H a, SWEEPS CODE <br /> ADDRESS 7 7 8 ' arv� Is' 0 G TANK iD # - d7� <br /> TANK SIZE (D DDD FUEL TYPE �;ese I �Di 00 AS D-rL Si -PG r vLS�ec--h B-✓� . <br /> 11. GENERAL SITE HISTORY *** <br /> is permit current? Yes No Permit # - Facility Status Code Dae.Soil/GW Cont Yes No <br /> (Number of Tanks at facility Age of TanksCif available) Type of Tank Steel Fbrgl Sns Dual <br /> 111. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test 7 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 No Were soil samples ana lyzed7 Yes No BTXE TPH-G TPH-D Pb/EDB <br /> Type of failure/discharge catastrophic tong-term Leakage overfill unknown other: <br /> 1V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Saaples Received Yes No Depth to Ground Water5 <br /> 10 Raf/Yeer �!D; Average Annual Precipitation A-114 10-25 <br /> On-Site WeIL(s) Yea No Nunber L Type Irr Dam Pub <br /> S Score 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 condition R condition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> r ' f <br /> Xinimua Depth to groundwater frac the Soil Sample (feet) 'JrQ- >100 51-100 25-50\1,j <br /> Fractures in subsurface (applies to foothills or mountain areas) O None Unknown Present <br /> Average Annual Precipitation (inches) xxxxxz <10 9 10-25 xxxxxxz 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) None Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At least More then <br /> Xxxxxx Xorx � one �rone <br /> COLUMN TOTALS» 9>TOTAL POINTS O * -7 1 <br /> Saap Le Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts WD 40 pts or Less <br /> T CiP-) D 81 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 /> S Le Result: GASOLINE 1000 100 10 <br /> C { a J <br /> NO MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPN DIESEL 10,000 1000 100 <br /> FOOTNOTES: ***!f dccuoented soil and/or ground water contamination is present, do not—ce leaching potential <br /> ,,,lysis. (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 BTXLE are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOlPIENDATION/CONCLUSIONC_�KT� S 7ri" <br /> r'Nkk'L1 <br /> 1. Are BTX L E or TPH Concentrations > Allowable Levels *Yea No r o� - 5 `✓��.P�//� <br /> 2. Recommend Site Closure Yes No 'If Yea, Refer to Site Mitigation for Evaluation SP <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR PAs s es — L f <br /> CCNCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MI TICATION FOR EVALUATION YES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED / / <br /> NAME CF <br /> EVAL'JATCR <br /> EH 23 30 (UGTWKSHT)\5/90 <br />