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x <br /> SAN JOACU6 -0UHTY PUBLIC HEALTH SERVICES/ENV' IRONMENTAL ":" DIVISION <br /> I• JGST WORKSHEET FOR SITE CLOSURE EVALUATI( DATE <br /> o <br /> 'NAME OF FACIL.'Tx �� l/ 11 )t <br /> />�iG (SVErPS CCDE} <br /> IADORESSI z ,,e�z- (TANK ID *I Z - /7ij p <br /> (TANK SIZEI '42,V IFUEL TYPEI ���5�-� <br /> i <br /> Ii. 32NERAL SITE HISTORY <br /> Is permit current?IYes l No (Permit 3I - (facility Status Codel iDoc.Soil/GLi CarttlYes� INoI <br /> �NLmber of Tanks at facility) (Age of Tanks(if availadte)I IType of rank ISteet[ iFbrgtl ISngtl Ouati <br /> ETI. TANK HISTORY <br /> [was tank tested? Yesl IN-1 (Failed precision test ?IYesl [Nol If yes, give date(s)i <br /> 'etas a repair made co the tank system7lYes) No, (If yes, what was repaired?I <br /> !Vas repair done under inspection?iYes l NoI Were soil samples anatyzed?IYesI INo( STXEI ITPk-G) iTPN-Di P6lQ B( <br /> Type of failure/discharge) (catastrophic) [long-term leakage) IaverfiIti (unknown other- <br /> V. Re4OVAL HISTORY (ATTACH INSPECTICN REPORT FOR SITE OETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Sail Samples Received Yes INoI IOe.orh co Ground SuterI-Vol Ref/Year 43 Average Annual PrecipitationlA=I 14 I10-75 <br /> On-Site 4e(L(s)IYes i INoI (Number & Typel IIrrI 10cmi IPI 11 <br /> (Distance Co '.tetL(s) from Tank "t; ft; S Scare S Scare S Score <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 I _ is met _ Iis .met <br /> Minimum Oepth to groundwater from the Sail Sample (feet) -7/ _l) I I >100 I o' 151-100 ` 125_50\1 <br /> !fractures in subsurface (acoties ca foothills or mountain areas) I None I I Unknown I JP iPresent I <br /> Average Annual Preeioitation (inches) jxxxxxxl <10 I 9 110-25 Ixxxxxxx+ 26-40\2 1 <br /> iMan-Made conduits which increase vertical migration <br /> iof Leachare (i.e_, septic systems, water wells, ponds) I None I f Unknown ! Present <br /> i <br /> Unique site features: Recharge area, coarse soil, nearly wet Ls. I G I At Least More than <br /> i1=144ane f1 1 one one <br /> 1 <br /> i COLUMN TOTALS>>>TOTAL POINTS I 1 + L I /© 1= ;-7 <br /> 1Sampte Result: 13 T X OR c') RANGE OF TOTAL POINTS 49 pts or more I 41 - 48 1 <br /> pts I 40 pts or less <br /> MAXIMUM ALLONABL= 3-T-X-E L.4VELS (PPM) 31 50I 50I 50 .3 .3 1. 1. XA\3 <br /> jSamote Result;. GASOLINE 1000 I 100 I 10 <br /> MAXIMUM ALLOWABLE TPN LEMS (PPM) <br /> f �?00 .Jr1� rr__TFH-v DIESEL 10,000 I 1000 I 100 i <br /> FOOTNOTES: 'Tf documented snit and/or ground water contamination is present, do not complete the Leaching potential <br /> analysis_ Ci-a-, site is c.urrentty on UGT Contamination List for soil or ground water.) <br /> \1 If depth is > 5 ft. and < 25 ft., scare O points_ If depth <=5 ft., do not use table. <br /> \Z If precipitation is > Q inches, score Cl points. <br /> \3 Levets for 3TX&E are not appticabte at a -IpN concentration of 10 ppm (gasoline) or 100 ;*w (dieset). <br /> VI. STAFF REC�.OMMENDAT/ON/CONCLUSION <br /> i_ Are 3TX & E or TPN Concentrations > Attowabte Levets '^fes) INoI <br /> i2. Recarrtnend Site ClosureIYesi INoI IL'If Yes, Refer to Site Mitigation for Evatuation+ <br /> VII. REVIEW -VALUATION - TO 3E CC�iPL�iIM A -UP0—RVT SE{IOR <br /> CONCUR 'aITH STAFF RECOMM@IDATFON FOR CLL>,A)RE!YESi NOi IREFFEWED TO SITE MITIGATION FOR EVALUATiONIYESI 110, <br /> DATE REFERREDI J ( / I DATE CLOSURE L---,7a 4AILQ I <br /> NAME OF <br /> EVALUATOR <br /> E:1 73 30 (UGT1dKSHT)\5/ <br />