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NAME OF FACILITY <br />TANK SIZE <br />11. GENERAL SITE HISTORY <br />SAN ICAOUIM OY PUBLIC HEALTH SERVICES/ENVIRONME4TAL HE0IVISION <br />wGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br />SWEEPS CODE 3 / 7 <br />L%... Ed <br />TANK IDB - `t' <br />EL TYPE <br />s permit current? Yes No Permit B - Facility Status Code Doc.Soil/GW Cont Yes No <br />mber of Tanks at facility Age of Tanks(if available) Type of Tank I Steel Fbrgl Sngl DualI <br />III. TANK HISTORY <br />Was Tank tested? <br />Yes <br />No <br />Failed precision test 7 <br />Yes <br />Ref/Year <br />No <br />If <br />yes, give date(s) <br />14 <br />Was a repair made to the tank system? <br />Yes <br />No <br />If yes, what was repaired? <br />Was repair done under inspection? <br />Yea <br />Irr <br />No <br />Dom <br />Were soil samples analyzed? <br />Yes <br />01 <br />1 <br />BTXE <br />TPN -G <br />TPH-D <br />Pb/EDB <br />Type of failure/discharge <br />catastrophic <br />long-term leakage <br />overfill <br />unknowm <br />Score <br />10 pts <br />other: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />Soil Samples Received <br />Yes <br />No <br />Depth to Ground Water <br />YES M <br />Ref/Year <br />Average Annual Precipitation <br />A• <br />14 <br />10-25 <br />On -Site Wells) <br />Yes <br />No <br />Number L Type <br />Irr <br />Dom <br />Pub <br />S <br />C <br />Score <br />10 pts <br />S <br />C <br />Score <br />9 pts <br />S <br />C <br />Score <br />5 pts <br />Distance to Vell(s) from Tank <br />ft; ft; ft <br />0 <br />R <br />if <br />condition <br />0 <br />R <br />if <br />condition <br />a <br />R <br />if <br />condition <br />V. Site Feature - Leaching Potential Analysis <br />E <br />is met <br />E <br />is met <br />E <br />is met <br />Minimum Depth to groundwater from the Soil Sample (feet) <br />>100 <br />51-100 <br />25-50\1 <br />Fractures in subsurface (applies to foothills or mountain areas) <br />None <br />Unknown <br />Present <br />Average Arcual Precipitation (inches) <br />xxxxxx <br /><10 <br />9 <br />10-25 <br />xxxxxxx <br />26-40\2 <br />Man -Made conduits which increase vertical migration <br />of leachate (i -e., septic systems, water wells, ponds) <br />None <br />Unknown <br />Present <br />Unique site features: Recharge area, coarse soil, nearby wells. <br />At least <br />More than <br />xxxxxx <br />None <br />one <br />one <br />,�(� <br />V I A Y <br />c IAjq/COLUMN TOTALS» >TOTAL POINTS <br />+ <br />+ <br />Sample Result: ( T OR E) <br />D-3 -NP =N'� <br />D y, r )U� <br />RANGE OF TOTAL POINTS <br />49 pts or more <br />41 48 pis <br />40 pts or less <br />R <br />T <br />X <br />E <br />B <br />T <br />X <br />E <br />MAX IMIAI ALLOWABLE 8-T•X-E LEVELS (PPM) <br />1 <br />50 <br />50 <br />50 <br />3 <br />.3 <br />1. <br />1. <br />NA\3 <br />Sample Result: <br />GASOLINE <br />1000 <br />100 <br />10 <br />MAXIMUM ALLOWABLE TPN LEVELS (PPM) <br />10,000 <br />1000 <br />100 <br />TPN <br />DIESEL <br />documented soil and/or ground water contamination is present, do rot complete the leaching potentialanalysis.(i.e., <br />site is currently on UGT Contamination List for soil or gradwater.) <br />1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth «5 ft., do not use table.2 <br />[7.If <br />If precipitation is > 40 inches, score 0 points. <br />3 Levels for BTXEE are not applicable at a TPR concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br />VI. STAFF RECOMMENDATION/CONCLUSION/ 1,,I,,��,/I�j�I���E �}-I <br />1. Are BTX b E or TPN Concentrations > Allowable Levels 'Yes No D- t/tZ <br />�2. Recommend Site ClosureYes NoIf Yes, Refer to Site Mitigation for Evaluatli�onD 3 Ir,TU F ,= ��, VII. REVIEW EVALUATION - TO BE CCMPLET BY ASUPERVISOR/SENIOR nSZ Al' u"` /1 ti � l:1 m<i/ _ <br />CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE <br />YES <br />NO <br />REFERRED TO SITE MITIGATION F EVALUATION <br />YES M <br />NO <br />DATE REFERRED <br />/ / <br />DATE CLOSURE LETTER NAILED <br />/ / <br />NAME OF <br />EVALUATOR <br />EH 23 80 (UGTWKSHT)\5/90 <br />