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SAN ICACUIN NTY PUBLIC HEALTH SERVICES/ENVIRCNMENTAL Hi DIVISION <br /> I. GST WORKSHEET FOR SITE CLOSURE EVALUATION W FIE( D <br /> ­71-NAME OF FACILITY I e S4EE.°S CCOE11 <br /> ADDRESS( (TANK ID 3 d�IS <br /> (TANK SI2EI <br /> III. GENERAL SITE HISTORY L <br /> Is permit current?IYes Nal IPermtt 3I IFaciliry Status Codel o lIDap.Soit/GW Cont`Yell INo�` <br /> INL=er of Tanks at facitityl Age of Tanks(if avoitable)I (Type of Tank isteel IFbrgll ISngt) Dual <br /> III. TANK HISTORY 0. 0476 <br /> Was Tank cested? Yes No (Failed precision test ?(Yes lNo IIf yes, give date(s)1 0 <br /> Was a repair made to the tank systehs?IYesI No IIf yes, what was repaired?I O <br /> Was repair done under inspection?iYes 1 INoI IWere sail sasoles analyzed?IYes I INoI 3TXE) ITPH-G! TPH-OI IPb/©BI <br /> Type of failure/discharge? (catastrophicI hong-term Leakage! Ioverfiltl Iwhdownl loner-. <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEAo m POTENTIAL ANALYSIS) <br /> iSoiL Samoles .ReceivedI Yesl INoI !Depth to Ground Water? (Ref/Year) (Average Aruna! Precipitation)A=114 110-25 <br /> On-Site Welt(s)1 YesI INo1 Ntadur 4 Type1 11rr1 (Ooa! iPuo1 <br /> 5 Score S Score S Scare <br /> Distance to We(L(s) frau Tank) it. ft; ft C 10 pts C 9 Pts C5 pis <br /> D if 0 if O f <br /> R carditian R condition R Condition <br /> Iv. Site Feature - leaching Potential Analysis - is met is mer ( _ his met <br /> I <br /> Minim Oepth co groundwater from the Soil Sahmte (feet) 1 I >100 I 151-100 I I. 25-50\1 <br /> Fractures in sucsurface (applies to fccthills or aawtain areas) / O 1 None I ( Unknown I jPresent <br /> (Average Annual Precipitation (inches) I:axxxxj <i0 I 9 1 10-5 J=Pooct! 25-40\2 <br /> I <br /> Man-Made conduits which increase vertical migration ! <br /> of leachate (i.e., septic systems, water wet Ls, ponds) V None I Unknow I iPresent <br /> Unique site features: Recharge area, coarse sail, nearby 'wells. xxxx>uI At least) More than <br /> None ane one <br /> All,-A <br /> COLNlN(7TALSA»TOTAL POINTS D 09 • = �� <br /> Saincle ResuL (tI X ORR S) ` RANGE OF TOTAL POINTS 49 2cs or more I 41 - 48 pts 40 pts or Less <br /> 3 U MAXIMUM ALLOWABLE 3-i-X-E LEVELS (PPM) tl 50 50` 50 .3 .3 X. 1. NA\3 <br /> Sample Result: GASOLINE 1000 100 I 10 <br /> MAXIMUM ALLOWABLE TPR LEVELS (PPM) <br /> TPH DIESEL 10,000 1 1000 RCC <br /> FOOTNOTES: " Tf documented sail and/or ground water contamination is presenc, do not coeolete the teaching potential <br /> ana Lysis. (i.e., site is aarehcty on UGT Contamination List for sail or ground water.) <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth c5 ft., do hot use table. <br /> \2 If precipitation is , 40 inches, score 0 points. <br /> \3 Levels for 3TXSE are not applicable at a TPN =rwencracion of TO ppa (gasoline) or ICO Woo (diene(). <br /> VI. STAFF RECOMMENDATION/CONCLUSION 13TO( (,.07,OW 4cAe-?c& 4 ev11K w <br /> I. Are 3TX 3 E or TPH Concentrations > Al Lowable Levels I-Yes 001 V ���Tj� <br /> 2. Recommend Site Ctosum Yesl INoI uation\ If Yes, Refer to Site Mitigation for Eval �� k,?, r%/M5 <br /> VII. REVIEW EVALUATION - TO 3E CCMPLETED SY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECCMME40ATICN FOR CLOSURE YES( I IRE.ZRED TO SITE MITIGATION FCR EVALUATIONITESI <br /> 1 DATE REFERREDI / / jj (DATE CLOSURE LETTER 9AILEDi / / I <br /> NAME OF <br /> EVALUATOR( <br /> EH 23 80 (UGTWKSHT)\5/90 <br />