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SAN JCACUIN NTY PUBLIC HEALTH se`RVICEs/ENVIRONMENTAL HDIVISION <br /> I GST WORKSHEET FOR SITE CLOSURE "EVALUATION IDATEI 9. i <br /> NAME OF FACILITYC/ SWEEPS CODE( <br /> 1ADDRESSI £ S -t� ITANK ID =l / 0 <br /> ITANK SIZEI'r/)_to IFUEL <br /> It. GENERAL SIT, HISTORY <br /> Is permit current?1Yes INo )Permit 3l - (Facility Scacus Codel IDoc.Soi L/CW ContlYeal IMCI <br /> Numoer of Tanks at facitiry 5 Age of Taraus(if available) a!� (Type of Tank!Steell IFbrgll IsngLI Ouatl <br /> III. TANK HISTORY <br /> Was Tank tested? Yes INo IFaited precision test ?I Yes IXIMCI !If yes, give date(s)J,3 // /PA / / <br /> Was a repair made co the tank system?lYesl NoI IIf yes, what was repai red?1 ?.4 <br /> Was repair done under inspection?(Yes INoI IWere soil samcles anatyced?I Yesl INoI BTXE ITPH-GI ITPH-Dl IPb/mBI <br /> Type of failure/dischargeI IcatascrophicI (long-term leakage) Io,erfiLLI 'unknown) lother: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE OS AILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> (Soil Samptes Received Yesl INoI (Depth :o Ground Water) (Ref/Year (Average Annual PrecipitationlA=114 110-25 <br /> On-Site Wetl(s)IYes I INoI 1Nnmber 4 Type Irrl )Dom' IPun I <br /> S Score s scz- <br /> S iScare <br /> Distance to Wells) from Tank ft; ft; tt C 10 pts C C 5 pis <br /> 0 if 0 0 if <br /> 3 condition 3 tian R epnditi0n <br /> V. Site Feature - Leaching Potential Analysis is ext _ is met a is met <br /> Minimum Depth :o groundwater from Che Soil Sample (feer)J 0"-5 I I -Ica 151-iD0 l l a5-50\1 <br /> �Fr3c:ures in subsurfaca (applies to fcothills or mountain areas) ! Pone 1 I Unkn0un I Present <br /> (Average Annual Precipitation (inches) xxx= d0 I 9 110-25 Ixxxxxcti 25-40\2 <br /> h4an-Made conduits which increase verticat migration <br /> Hof teachate (i.e., septic systems, water we(ls, ponds) More Unknown !Present <br /> Unique site features: Recharge area, coarse spit, nearoy wells. At least Mare than <br /> )COO cl None I one, ( one <br /> I � <br /> COLUMN TOTALS»>TOTAL POINTS I • I= � <br /> Sample Result: (s T X OR E) RANGE OF TOTAL POINT 49 pts or more 41 - 49 pts I :0 pts or less <br /> 3 7 X 3 i X _ <br /> MAXIMUM ALLOWABLE 3-T-X-E LEVELS (PPM) tl '-0� 501 50 .3 .3 1. 1. I 4A\3 <br /> sample Result: GASOLINE 1000 100 10 <br /> MAXI" ALLOWABLE TPH LEVELS (PPM) <br /> TPH DIESEL 10,D00 1000 100 <br /> 97;FOOTNOTES: ' Tf documented soil and/or ground water contamination is present, do eie the Leeching potential <br /> arstysis. (i.e., site is currmcly on UGT Contaminaci0n 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 BTXSE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> I. Are 3TX b E or TPH Concentrations > At towable Levels I-Yesl INo <br /> 2. Recommend Site Ctosurel Yesl INoI I If Yes, Refer to site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO 3E COIPLETETI. BY A SUPERVISOR/SENIOR <br /> CCMCUR WITH STAFF RECOMMENDATION FOR CLOSURE TESD INoI IRS-ERRED M SITE MITIGATION FOR EVALUATION(YEsl NO l <br /> DATE REFERRED( / / (DATE CLOSURE LETTER MAILED( <br /> NAME OF <br /> EVALUATORI <br /> EH 23 80 (UGTWKSHT)\5/90 • <br /> • <br />