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SAN dOAflUI> •UN TY PUBLIC HEALTH SERViCrS/ENVIRONNENTAL i. .j1A DIVISION <br /> I SGST WORKSHEET FOR SITE CLOSURE EVALUATION. DATE r� <br /> NAME OF FACILETY SWEEPS CODE <br /> IAOORESS �i r TANK ID <br /> TANK SIZE ` FUEL TYPE /� <br /> (I. GENERAL SITE HISTORY <br /> Is permit current?lyes / No Permit ;*I <br /> - )facility Status Code) Dac.SaiL/GW Cx= Yes No <br /> Number of Tanks at facility )Age of Tanks(if availabLe) Type of Tank Steel L�11_lFbrgl Sngi Dual <br /> I. TANK HISTORY <br /> Was Tank tested? Yes Na X Failed precisian.test 7 Yes Na If yes, give dare(s)I <br /> Was a repair made to the tank system; Yell No Itf yes, what was repo ired?l t-1 h. A 0 U) <br /> Was repair done under inspection? Yes Nol Were sail samples analyzed? Yes No BTXE TAH-G TPR-O Pb/EDS <br /> Type of failure/discharge) catastrophic) Long-term leakage overfill unknawut other: i <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yesl No Depth to Ground water Ref/Yearl Average ArmuaL PrecipitatianlA= 14 10-25 ! <br /> on-Site WeLI(s)lYes No lNumber & Type Irr Dam Publ <br /> S Score S Score S Score <br /> Distance to WeLI(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> O if 0 if O if <br /> R condition R condition R condition <br /> V. Site Feature - Leaching Potentia[ Analysis a is met E is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet) l >100 51-100 l l 75-50\1 <br /> Fractures in subsurface (acp0 es to foothills or, mountain areas) 0 I None I I Unknown l )"26- \2 <br /> Average Annual Precipitation (inches) lxxxxxxl <10 i 9 l 10-75 lxxxxxxxl <br /> Man-Made conduits which increase vertical migration <br /> of Leachate (i.e., septic systems, water weLLs, ponds) I None I q Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby weLLs- II At Least) than <br /> + X%XX7OC� None I I <br /> one IMare <br /> one <br /> i I ff III <br /> COLUMN TOTALS)»TOTAL POINTS <br /> Sampl u7C- (8 X Dim RANGE Of TOTAL POINTS 49 Pts or more 41 - 4$ pts I 40 pts or Less <br /> Aro 0,014 nID <br /> a T x E a T X E <br /> 1 1 2 3. 0 MAXIMUM ALLOWABLE 8-T-x-H LEVELS (PPM) 1 50 5O 50 .3 -3 1. 1- NA\3 <br /> Sample Result: I HrRASCLIME 1000 I 100 10 <br /> P.� MR4 N1� 17491 " IMAXIMUM ALLMMLE TPH LEVELS (PPM) l <br /> f <br /> 1,442 1PUQ `tel _ TPH�. b 10,000 1000 100 <br /> FOOTNOTES: 'If documented soil and/or ground water contamination is present, do not comptete the leaching potential <br /> analysis. (i.e., site is currentty an UGT Contamination List for soil or ground water.) <br /> ° \1 If depth is > 5 ft. and C 25 ft-, score 0 points_ If depth (--5 ft., do not use table. <br /> \Z If precipitation is > 40 inches, scare 0 points- <br /> \3 Levels for 9TX&E are not appticabte at a TPH concentration of 10 ppm (gasoline) or TOO ppm (diesel)- <br /> 1 VI. STAFF RECOMMEHOATION/CONCLUSION 1 <br /> l JL h <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levet_, 'Yes) No <br /> . 'iP1-FID IUUOQ �►. <br /> 2. Recanmend Site Ctosure Yes Nol l If Yes, Refer to Site Mitigation for Evaluation c�-`-4— <br /> J <br /> VII- REVIEW EVALUATION - TO SE COMPLETED 3Y A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMNE40ATION FOR CLOSUREIYES NOf REFaRED TO SITE MITIGATION FOR EVALUATIONIYESI INCI I <br /> DATE REFERRED ! / (DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EM 23 80 (UGTWKSHT)\5/90 <br /> 1 <br />