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SAN JOAWIr ''Y/ -48LIC HEALTH SERVICES/ENVIRONMENTAL-NE' i D—TSION <br /> IA%e0KSHEET FOR SITE CLOSURE EVALUATION <br /> DATE <br /> NAME Of FACILITY G��/ <br /> ADDRESS SWEEPS CODE l b <br /> 64 <br /> TANK ID # <br /> TANK SIZE 6 FUEL TYPE /E - t066-6( <br /> II. GENERAL SITE HISTORY <br /> Is permit Currant? Yes No Permit M Facility Status Code Doc-Soil/GW Cont Yes No <br /> Number of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl Sntgl Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No Fasted precision test ? Yes No If yes, give dates) / ! <br /> / ! <br /> Was a repair made to the tank system? Yes NCI If yes, what was repaired? <br /> Was repair done oder inspection? Yes No Were soil samples analyzed? Yes No BTXE 7PN-1 <br /> TPH•D Pb/®B <br /> Type of failure/discharge Catastrophic long-term leakage overfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soit Samples Received Yes zx1mo Depth to Grand Water Ret/Year <br /> gb ; Average Amort Precipitation An 14 10-25 <br /> On-Site Welts) Yes No ' Number i Type Irr , Dam Pub <br /> Distance to Wetl(s) from Tank —ft; ft• S Score S Scare S Scare <br /> 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 Soft Sampte (feet) >100 51-100 D 25-50\1 <br /> Fractures in subsurface (app(ies to foothills or mountain areas) None 411 Unknown Present <br /> Average Annual Precipitation Cinches) xxxxxx <10 9 10-25 xxu xx 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water welts, ponds) None Unknown Present <br /> Unique site features: Recharge area, Coarse soil, nearby watts. At least More than <br /> xxxxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS <br /> Sample Result: CS T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> B T I XE B T X E <br /> MAXIM M ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Resutt: GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> DIESEL 10,000 1000 <br /> FOOTNOTES: ***If documented soil and/or ground water Contamination is present, do not complete the teaching potential <br /> analysfs. (i.e., site is currentty on UGT Contamination List for soit or groud water.) <br /> \1 If depth is > 5 ft. and < 25 ft., scare 0 points. If depth <_5 ft., do not use table. <br /> \2 If precipitation is-2,40 inches, score 0 points. <br /> \3 levels for 8TX3E 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 > Attowobte Levels *Yes No � �— <br /> 2. Recommend Site CtosureYes No If Yes, Refer to Site Mitigation for Evaluation - <br /> VII. REVIEW EVALUATION - TO 8E COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE+YES I NO I REFERRED TO SITE MITIGATION FCR EVALUATION TES NO <br /> DATE REFERRED H / (6 DATE CLOSURE LETTER MAILED <br /> NAME Of � <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />