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SAN JOA0U1N '' NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE& DIVISION <br /> I. ST WORKSHEET FOR SITE CLOSURE EVALUATION DATE( (a <br /> G L <br /> NAME OF FACILITY l �� G ��— �1 <br /> l G3-'t-�.r l SWEEPS CODE I <br /> (aooaess 3U35-0 (3LVC� (TANK ID $l <br /> TANK SIZE 5(po (FUEL TYPE � ©L <br /> II. GENERAL SITE HISTORY <br /> Is permit current?(Yes No Permit ( - (Facility Status Code IDcc.Soil/GN Cant,Yes Nol <br /> Number of Tanks at facility+ (Age of Tanks(if available) t Type of Tank Steel Fbrgl Sngtiv, Oual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes / No Failed precision test ? Yes No If yes, give date(s) <br /> Was a repair made to the tank system? Yes NOF IIf yes, what was repaired?l <br /> Was repair done under inspection?l Yes Nol Were sail samples analyzed? Yes Na BTXEI (TPH-GI TPH-0 lPb/Mal <br /> Type of failure/discharge, catastrophic hong-term leakage IaverfiILjq_funknown I Iother: l <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes l No Depth to Ground Waterl5DlRef/Year Average Annual PrecipitationlA= 14 10-25 <br /> On-Site Well(s)lYes V1 <br /> No lNumber & Type Irr Dom IPubl <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 /> 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 /> lMinimum Depth to groundwater from the Soil Samote (feet) ! >100 l I51-100 ' ( 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) l Norte l l Unknown l (Present l <br /> (Average Annual Precipitation (inches) (xxxxxxl <10 i 9 l 10-25 jxxxxxxx, 26-40\2 <br /> �Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) ` None I I Unknown ! j Present <br /> I <br /> (Unique site features: Recharge area, coarse soil, nearby wells. M ) I At Least More than <br /> xxxxxxf` None one J� one <br /> COLUMN TOTALS>>>TOTAL POINTS I + I , I + /S- <br /> (Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts I 40 pts or less <br /> IBITIX � 5 1 .9J.TIX1E I <br /> MAXIMUM ALLOWABLE B-T-X-e- LEVELS (PPM) 1 50 z0 70 3 3 1. i. NA\3 <br /> SaiT:tola R utt: GASOLINE 1000 l 100 I 10 <br /> iym i�tj 1� MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH c is DIESEL 10,000 l 1000 l 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 or ground water.) <br /> \1 If death is > 5 ft. and < 25 ft., scare 0 points. If depth <=5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> Vi. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Atlawabie 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 RECOMMENDATION FOR CLOSUREIYES tjf0j REFERRED TO SITE MITIGATION FOR EVALUATIONIYESI NCI I <br /> DATE REFERRED+ / ✓�2_ / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR Lb/, 'WA_� <br /> EH 23 80 (UGTWKSHT)\5/90 <br />