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SAN 10AD1 7UNTY PUBLIC HEALTH Sc^RVICES/ENVIRONMENTAL TH DIVISION <br /> I . UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE [ �•-" <br /> I <br /> I. NAME OF FACIL [ T�yYr � /�H, � 6Qnv 1 C /.,, / SNEEPS CODE [ C J / ? <br /> ADDRESS J F/ LGA v�G) C / l y—YfylJ TANK f0 XI3 (^,• / � � 7 — Q! Sf% <br /> TANK SIZE I FUEL TYPE f,2 GO. aa <br /> [ I . GENERAL SITE HISTORY ��` /// I� _ <br /> Es permit current? Yes [ 7( INoI Permit . I ! Facility Status Codel 0 j IDac. Scil /T4 Cant Yes ! Nal <br /> j .4umber of Tanks at faciLiry [ Age of Tanks( if available) Type of ianklSteell lFbrgl ' ISngII Dual ' <br />.! II1 . TANK HISTORY <br /> was Tank tested? I Yesl NoI ( Failed precision cast ? I Yes No If yes , give dace(s ) I <br /> ; Has a repair made to the tank system? [ Yes No If yes , wnat was repaired? I <br /> Alas repair done under inspection? lYesl INoI Were soil sanoles analyied? IYesl11011� BTXE ! [ TPH-Gj TPH-0 ' Pb/EDB [ <br /> ', Type of failure/dischargel Icarastrophicl ( long- term leakage ! [ overfill ! unknown) other : <br /> IV . REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes INoI IOepth to Ground Yater boIRef/Year ! 6 ' Average Annual Precipitation A= 114 110- 25 <br /> ion- Site 'Jett ( s ) Yes No ! INuncer d Type [ rr Dam{ IPubI <br /> S Score SScore S Score <br /> ! Distance to WeLL ( s ) from rank ) ft; ft ; ft C 10 pts C 9 pts C 5 ots <br /> O if D if 0 if <br />! L R condition i condition R condition <br /> ! V . Site Feature Leaching Potential Analysis / = 3C/ is net _ its met � c is ret <br /> Minim Depth to groundwater from the Soil Sample ( Peer ) ( I > 100 1 151 - 100 i S 1z5I,50\ 1 <br /> , Fractures in subsurface ( applies to foothills or mountain areas ) I .None ' Unknown ! ! Present <br /> . .Average Annual Precipitation ( inches) Ixzxxxx` <l0 i 9 ' 101125 Ixxx:axX ! 26-40\2 <br /> ,Man-Made conduits which increase vertical migration i <br /> , of teacnare ( i . a . , septic systems , water wells , ponds ) 1 /01 None I I Unknown I Present <br /> 11••�� Dunique site features : Recharge area , coarse soil , nearby weL Is. I I At least More :han <br /> L o _ 0 G+-3L� X xxxxxx ' None I ane one <br /> . 03 X s , ,may � � D I . <br /> S i ,— e Ib X _ CD M " 71 > TOTAL POINTS `/� � <br /> ; Sample Result: ( 3 T X OR -c) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pcs or less <br /> D1 j= ND Da7-� <br /> A f % • j6 V' Fes •• az q © M MUM ALLOWABLE 3- T-X-? LEVELS (PPM) 13 <br /> SDI 30 5 <br /> 0 .3 .3 1 . 1 , 4A\3 <br /> 1J <br /> Sampigiesult : GASOLINE 1000 I 100 10 <br /> D43MAXIMUM ALLOWABLE TPH LEVELS (PPM[ <br /> DO K TPX O [ ESEL 1D , OW 1000 I 100 <br /> FOOTNOTES : >"*lf documented soil and/or ground water contamination is present, do not ere rhe Leaching potential <br /> � � ._ 3,-7 & TPHI analysis- ( i . e. , site is currently on UGT Contamination List for soil or ground water , ) <br /> — Ic Z T�n yl� f depth is > 5 ft- and < 25 ft. , scare 0 points . If depth <i ft. , do nor use cable. <br /> 1-11.2 [ f precipitation is > 40 inches , scare 0 points. <br /> \3 Levels for 3TXSE are not applicable at a TPH concentration of TO ppm (gasoline) or 100 ppm (diesel ) , <br /> V( . STAFF RECOMMENDATION/CONCLUSION J1 slop at <br /> C` • L 1/ 'E.' <br /> aannna <br /> 1 , Are BTX 3 E or TPH Concentrations > At towable Levels I *Yes Nal � . /GL1�LfJGWL1 en <br /> 2 . Recommend Site Closure Yesl INa >1*If Yes , Refer Site Mitigation for Evaluation 7�/ n _ �;a�r G/y <br /> N <br /> L�(X�J r-' "TWY <br /> VII , REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE I YESI [ MCI ( REFERRED TO SITE .MITIGATION FOR EVALWATIONIYESI IND ! <br /> i <br /> DATE REFERRED ! / / IOATS CLOSURE LETTER 14AILEDI / / <br /> NAME OF <br /> EVALUATOR <br /> EH 23 30 CUG"'wKSHT ) \5/90 <br />