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SAN .10AOUIN CCU' " PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH%IVISIOH <br /> V WORKSHEET FOR SITE CLOSURE EVALUATION 4 DATE <br /> jF FACILITY C dr•+ �. 5 CODE .7 <br /> TANK IA 4 - <br /> fAHK SIZE r 5 FUEL TYPE r—CX p <br /> d.S <br /> .SII. GENERAL � a� <br /> Is permit current? Yes Na ermit g - Facility Status Code e Doc Soil/GLI Cant Yes No <br /> Number of Tanks at facility Age of Tanks(If available) 5 : Type of Tank Steel X Fbrgl Sngt Dual <br /> III. TANK HISTORY <br /> 1 <br /> was Tank tested? Yes 4 <br /> No Failed precision test ? =e3mo If yes, give dates) <br /> Was a repair made to the tank system? Yes NQJ�4 If yes, what was repaired? <br /> Was repair done under inspection? Yes No Were sail samples analyzed? Y,es No STXE TAH-G TPH-0 Pb/EDB <br /> i <br /> Type of failure/discharge catastrophic long-terse Lee kage overfill unknawn other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Ground Yater g) Rat/Year cab '; Average AnnualfPrecipitation Am 14 10-25 <br /> On-Site Welt(s) Yes1,14 No Number & Type Irr Oam 1 Pub . <br /> S Score S Scare S Scare <br /> Distance to Welts) from Tank 20 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 Sail Sample (feet) >100 51-,i00 S ?.5-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx <br /> <10 9 10-25 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of Leachate (i.e., septic systems, water wells, ponds) None Unlau ml Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At; least more than <br /> xxxxxx None one one <br /> COLUMN TOTALS>»TOTAL POINTS + + LO = <br /> Sample Result: (Ii T X OR E) RANGE-OF TOTAL POINTS 49 pts'-or more 41 - 48 pts 40 pts or Less <br /> v B T X I E B 1 T X E <br /> MAXIMUM ALLOWLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 i. 1. NA\3 <br /> Sample Result: GASOLINE taco 100 10 <br /> MAXIMIAI ALLOWABLE TAH LEVELS (PPM) <br /> S D o0 TPH DIESEL 10;000 loco. 100 <br /> FOOTNOTES: If documented soil and/or ground water contamination is present, do not complete the Leaching potential <br /> analysis. (i..e., site is currently an UGT Contamination List for soil os ground water.) <br /> \1 If depth is > 5 ft. and < 25 ft., scare 0 points. If depth —5 ft., do not use;tabie. <br /> \2 if precipitation is > 40 inches, scorn 0 points. <br /> \3 Levels for STXSE are not applicable at a TPH coscentratioh of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> I: Are BTX $ E or TPH Concentrations > Allowable Levels *Yes No <br /> 2. Recortmend Site Closure Yes No If Yes, Refer to Site Mitigation for Evaluation <br /> VII.=REVIEW EVALUATION - TO Be COMPLETED 8Y A SUPERVISOR/5 ICR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES N0 REFERRED TO SITE'MITIGATICN FOR EVALUATION YES <br /> HATE REFERRED / / DATE45118 LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />