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.ti . <br /> SAN JOADUI . Y PUBLIC HEALTH SERVICES/CNVIRONMENTAL VISION <br /> q I JGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> t /� />� n Y t _ <br /> " L..tG r r S Rit I SWEEPS CCOE I a� J <br /> NAME OF FACILITY I /\. „ .L V 1 <br /> ETANK <br /> RESS / [�� N ( TANK ID #I <br /> SIZE FUEL TYPE � / <br /> II . GENERAL SITE HIST Y *+* <br /> Is pefmit current? Yes No ( Permit # - Facility Status Codel CJ Doc .Soi L/GW Cant Yesl No <br /> Nu er of Tanks at facility Age of Tanks( if available) Type of Tankl Steel FbrgLl SngLI Dual <br /> III , TANK HISTORY <br /> Was Tank tested? Yes X INo ( Failed precision test TYesl X Na I [ f yes , give dates ) /a- g/ $' <br /> Was a repair made to the tank system? Yes No If yes , what was repaired? ( <br /> ( Was repair done under inspection? IYes INo ( Were soil samples analyzed? Yesl INo ( BTXEI ITPH -G ITPH -0 Pb/EDB <br /> Type of failure/discharge ) Icatastraphic long- term leakage overfill unknown other : <br /> IV . REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS ) <br /> Sail Samples Received Yesl Nol Depth to Ground Water Ref/Year ; Average ArinuaL PrecipitationlA= 14 10- 25 <br /> I <br /> On- Site Well ( s ) Yes Nol INuioer & Type Irr low Pub S Scare S reandition <br /> . S Scare <br /> Distance to Wel l ( s ) from Tank ft ; ft ; ft C 10 pts C C 5 pts <br /> 0 T O D if <br /> R condition R R condition <br /> V . Site Feature - Leaching Potential Analysis E is met -e t E is mac <br /> 111 11 11 >100 51 - 100 25 - 50\1 <br /> Minimum Depth to groundwater from the Soil Sample ( feet )`-' <br /> I II 0 1 <br /> Fractures in subsurface ( applies to foothills or mountain areas ) <br /> None I I Unknown ( Present <br /> xxxkkx <10 9 10- 25 xXxxxxxl 2fi-40\2 <br /> Average Annual Precipitation ( inches ) I I <br /> Man-Made conduits which increase vertical migration 17\ I None I Unknown Present <br /> of Leachate 0 , e . , septic systems , water wells , ponds ) (� <br /> A least Mare than <br /> ( Unique site features : Recharge area , coarse sail , nearby wellsm xxxxxx <br /> More one one <br /> M � , COLUMN TOTALS>>>TOTAL POINTS v I ' <br /> Same le R'1esult : ( B T X OR E) <br /> /moRANGE OF TOTAL POINTS 49 pis or more I 41 - 48 pts 40 pts or less <br /> pI D 1 <br /> I'I'I 8 T X E B T X E <br /> X a , I MAXIMUM ALLOWABLE B-T-X-E LEVELS ( PPM ) 1 50I 50 SO I .3 .3 1 . 1 , <br /> NA\3 I t <br /> Samole Result , 7f H''h'LD <br /> GASOLINE loco I 100 tU <br /> T P'K - G = 1 7 MAXIMUM ALLOWABLE TPH LEVELS CPPM) DIES`cL 10 , 000 1000 <br /> PM l 4 560 TPH ( Q } <br /> FOOTNOTES : *** If documented soil and/or ground waIF ter contamination is present , do not complete the leaching potential <br /> analysis . ( i . e. , site is currently an UGT Contamination List for soil or ground water. ) <br /> \1 If depth is > 5 ft . and < 25 ft . , score 0 points. If depth c5 ft. , do not use table . <br /> \2 If precipitation is > 40 inches , scare o points . <br /> \3 Levels for 9TX&E are not applicable at a TPH concentration of 10 ppm (,gasoline) or 100 ppm (diesel ) , <br /> ��/ , —� <br /> VI . STAFF RECOMMENDATION/CONCLUSION <br /> 1 . Are BTX 3 -E or TPH Concentrations > Allowable Levels 'Yes INo <br /> 2 . Recommend Site Closure Yesl No iI Yes , Refer to Site Mitigation for Evaluation <br /> VII . REVIEW EVALUATION - TO BE CCMPLI BY A SUPERVISOR SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSUREIYES NO IREFERRED TO SITE MITIGATION FOR EVALUATIONIYES INOI I <br /> / DATE CLOSURE LETTER MAILED <br /> DATE REFERRED ! / �1 <br /> NAME OF <br /> EVALUATORI <br /> EH 23 80 (UGTWKSHT ) \5/90 <br />