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PUBLIC HEALTH SERVICES/EHVIRONMEHTAL HEALT` y 1SI0N <br /> SAN JCiAOUIH Cr , <br /> WORKSHEET FOR SITE CLOSURE EVALUATION DATE Z/ —f <br /> I. <br /> SWEEPS CODE <br /> rz NAME OF FACILITY 1{,�,(_�,L11 '� '' ,� c. , C:� �3/ <br /> ADDRESS TANK (D 171 <br /> TANK SIZE `j!? <br /> II. GENERAL SITE HISTORY <br /> Is permit currenc?IYes NOVPermit $I (Facility Status Code Doc.Soit/GW Cont Yesl jmo <br /> N1 of Tanks at facility Age of ianks(if available)I(,vy.01 (Type of Tank Steel Fbrgl Snwgl Ouat <br /> III. TANK HISTORY <br /> Was Tanis tested? Yes No Failed precision test ? Yes No If yrs, give date(s) <br /> _G✓•t�i� <br /> Was a repair made to the tank system?! Yes No If yrs, what was repaired? t.VLG• �;� <br /> Was repair done under inspection? Yes Nal Here sail sraples analyzed?I Yes INC BTXE (TPH-G ITPH-0 Pb/EDB <br /> Type of failure/discharge catastrophic tong-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 Yes No Depth to Ground Water Ref/Year Average Annual Precipitation A= 14 10-25 <br /> On-Site WeLL(s) Yes No Number b Type! Irr Dao Pub <br /> S Scare S Scare S Scare <br /> Distance to WeLL(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> O 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 Che Sail Sample (feet) ! >100 I (51-100 ! 125-30\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None I I Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx <10 I 9 110-25 :0000=l 26-40\2 <br /> Man-made conduits which increase vertical migration <br /> of Leachate (i.e., septic systems, water wells, ponds) Nave I UnknownI Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. I I At Least More than <br /> x:oo= None ane ane <br /> COLUMN TOTALS»TOTAL POINTS <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more I 41 - 4a pts I 40 pts or less <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 9I 50 SOI 50 3 ('3 1.I 1. MAS <br /> S (a Resui oZ Q�'jai" <br /> GASOLINE 1000 100 10 ALLOWABLE TPH LEVELS (PPM) <br /> TPN DIESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or grand water contamination is present, do not complete the Le:dttng <br /> analysis. (i.e., site is currently an UGT Contamination List for sail or ground wetter.) <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth —5 ft-, do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTXSE are not applicable at a TPH concentration of 10 ppm Cgasotine) or 100 pp (diene!). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No <br /> Z. Recomtneshd Site Closure Yes No If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE CCMPL.ETED BY A SUPERVISOR/SEHIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSUREIYESIREFERRED TO SITE MITIGATION FOR EVALUATION <br /> NOIYES NO <br /> DATE REFERRED / / (DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />