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SAN JOADUI' .T. PUBLIC HEALTH SERVICES/ENVIRONMENTAL r -"%I DIVISION <br /> I' N,,i WORKSHEET FOR SITE CLOSURE EVALUATION <br /> OATS � <br /> NAME OF FACILITY <br /> � o QL SWErPS CODE( <br /> ADDRESS+ U 5 1 <br /> TANK SIZEFUEL TYPE <br /> �bb0 � <br /> II. GENERAL SITE HISTORY <br /> is permit current? Yes XNo Permit 8` - Facility Status Code Doc.Soil/GW Cant Yes, No <br /> Number of Tanks at facility JApe of TanksCtf available) ( Type of Tank Steel Fbrgl SNt Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes 1ANo Failed precision test t Yes xNo If yes, give date(s) <br /> Was a repair made to the tank systmhtt Yes Sol I If yes, what was repaired? <br /> Was repair done under inspection? Yes Mal Were soil samples analyzed? Yes No BTXE TPN-G TPN-D) 'Pb/EDS <br /> Type of failure/discharge catastrophic (tag-term Leakage overfill u*=.n other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACRIMG POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes Vol (Depth to Ground Water V � ef/Yearl 07;r Average Annual Precipitation A= 14 10-25 <br /> On-Site WeLL(s) Yes No Number i Type Irr Dam Pub <br /> S Score S Score S Saxe <br /> Distance to WeLL(s) from Tank 5c) 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 /> Minimum Depth to groundwater from the-Soil SaWte (feet) Q -100 51-100 125-SQ\i <br /> Fractures in subsurface (applies to foothilLs or mountain areas) None Unknown present <br /> Average Annual Precipitation (inches) X000ct <10 9 10-25 1=0=1 25-40\2 <br /> Man-Made conduits which increase vertical migration <br /> Of leachate (i.e., septic systems, water wells, ponds) Nene Lknknohah Present <br /> Unique site features: Recharge area, coarse soil, nearby weds. ( At Least `More than <br /> on <br /> �00000c Ne one I ane <br /> COLLM TOTALS>»TOTAL POINTS / + a 5 (: J <br /> Sampte Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 4 t 40 pts or Less <br /> n1I B TX E B IT X E <br /> gs� MAXIMUM ALL06ASU B-T-X-E LEVELS (PPM) t) 50 50 50 -3 .3 1. 1. '; NA\3 <br /> Sample Result: GASOLINE 1000 100 j 10 <br /> am�e� �.� THAXI" ALLOWABL: TPH LEVELS CPP") <br /> TPN DIESEL 10,000 �� 1000 100 <br /> FOOTNOTES: *"If documented soil arWor ground water contamination is present, do nor etl a 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 Q5 ft., do not use table. <br /> \2 If precipitation is >40 inches, score 0 points. <br /> \3 Levels for STUE are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX L E or TPN Concentrations > ALLowabte Levels 'Yes No <br /> 2. Reeamaernd Site Closure Yes MoJ �If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO 3E COMPLETED BY A =PERVISOR/SEHIOR <br /> CONCUR WITH STAFF RECOIN4ENDATION FOR CL=3REITES NO REFERRED TO SITE MITIGATION FOR EVALUATIONIYES INOI <br /> DATE REFERRED / / (DATE CLOSURE LETTER MAILED( <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />