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SAN JOAOUI�' 1PUBLIC HEALTH SERVICES/ENVIRONMENTAL 3' `' 'VISION <br /> I• I, WORKSHEET FOR SITE CLOSURE EVALUATIONI� DATE <br /> NAME OF FACILITY n art/ f F SWEEPS CODE <br /> STANKZE <br /> 7� �'. Lcac�vs� TAMC ID �� 111"f 3- UZ~ <br /> lU U FUEL TYPE �Gsc I 3� - J~{'C - 03 i <br /> I1. GENERAL SITE HISTORY <br /> *,e* <br /> Is permit current? Yes No Permit # - Facility Status Code Cal Doc.Soil/GW Cont Yes No <br /> Number of Tanks at facility rL..- Age of Tanks(if available) t Type of Tank Steel Fbrgl SngL Dual <br /> Iii. TANK HISTORY <br /> Was Tank tested? Yes o Failed precision test 7 Yes No If yes, give date(s) <br /> Was a repair made to the tank system? YesNo yes, what was repaired? <br /> Was repair done under inspection? Yes No Were soil samples analyzed? Yes No BTXE TPH-G TPH-D Pb/EDB <br /> i <br /> Type of failure/discharge catastrophic Eong-term Leakage overfill I unknown I 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 Water a Ref/Year Average Annual Precipitation A= 44 10-25 <br /> On-Site Well(s) Yes No Number & Type Irr Dom Pub <br /> 5 Score S Score 5 Score <br /> Distance to WeIL(S) from Tank ft; �� ft; ft C 10 pts C 9 pts' C 5 pts <br /> D if 0 if 0 if <br /> R condition R condition R condition <br /> V. Site,Feeture - Leaching Potential Analysis E is met E is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet) >100 51-100 25,50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) L(] None Unknown Present <br /> Average Annual precipitation (inches) xxxxxx <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 Unknown 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 t + <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or.less <br /> BT X E B T % E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3` <br /> Sample Result: GASOLINE 1000 100 10 <br /> �f MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> y- TPH DIESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the leaching potential ""y <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) } <br /> \1 if depth is > 5 ft, and < 25 ft., score 0 points. If depth <=5 ft., do not use table: I4 <br /> \2 If precipitation is > Winches, score 0 points. i <br /> \3 Levels for BTX&E are notlapplicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION S'�Z,C`C I t i l Z,5 ✓P yrt <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No <br /> 2. Recommend Site Closure Yes No *If Yes, Refer'to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMMENDATION FOR CLOSURE YES NO REFERRED 10 SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / ! DATE CLOSURE- LETTER NAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />