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I. <br />NAME OF FACILITY o <br />ADDRESS <br />TANK SIZE FU <br />Ir ecuco ei SITE HISTORY <br />SAN JOAQUINTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAODIVISION <br />OST WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br />c =SWEEPS CODE a /. <br />W � <br />I!]� J Sfo� .�� <br />EL TYPE TANK ID ` <br />J <br />permit current? Yes No Permit 9 Facility Status Code DOc.SOiL/GW Cont Yes) Na <br />anber of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl SngLI Dual1 <br />III. TANK HISTORY <br />Was Tank tested? Yes <br />INo <br />(Failed precision test ?IYes INoI IIf yes, give date(s) <br />Was a repair made to the tank system? Yes <br />No If yes, what was repaired? <br />Was repair done under inspection? Yes <br />No <br />Were soil samples analyzed? <br />Yesl INoI <br />BTXEI TPH-G TPH-D Pb/EDBI <br />Type of failure/discharge catastrophic <br />NAME OF <br />EVALUATOR <br />ILong-term LeakageT (overfill <br />unknown <br />other: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />F1 <br />-p', <br />Soil Samples Received <br />Yes <br />No Depth to Ground Water) <br />Ref/Year <br />Average Annual Precipitation <br />A=114 110-25 <br />On -Site WeLL(S) <br />Yes <br />IN.1 Number & Type <br />Irrl Dom <br />Pub <br />NAME OF <br />EVALUATOR <br />S <br />C <br />Score <br />10 pts <br />S <br />C <br />Score <br />9 pts <br />S <br />C <br />Score <br />5 pts <br />Distance to Wells) from Tank ft; ft; ft <br />0 <br />R <br />E <br />if <br />condition <br />is met <br />0 <br />R <br />E <br />if <br />condition <br />is met <br />0 <br />R <br />E <br />if <br />condition <br />is met <br />V. Site Feature - Leaching Potential Analysis <br />Minimum Depth to groundwater from the Soil Sample (feet) <br />>100 <br />51-10025-50\1 <br />Fractures in subsurface (applies to foothills or mountain areas) <br />I None <br />Unknown <br />(Present <br />Average Annual Precipitation (inches) <br />xxxxxx <br /><10 <br />I 9 <br />10-25 <br />'xxxxxxxl <br />26-40\2 <br />Man -Made conduits which increase vertical migration <br />of leachate (i.e., septic systems, water wells, ponds) <br />None <br />Unknown <br />Present <br />Unique site features: Recharge area, coarse soil, nearby wells. <br />At least) <br />More than <br />xxxxxx <br />None <br />one <br />one <br />COLUMN TOTALS> >TOTAL POINTS <br />+ <br />( + <br />Sample Result: (B T X OR E) <br />RANGE OF TOTAL POINTS <br />49 pts or more <br />- s <br />40 pts or less <br />B T <br />X <br />E <br />8 <br />XEMAXIMUM <br />ALLOWABLE B -T -X -E LEVELS (PPM) <br />t� 50 <br />50 <br />5 <br />.3 <br />3 1. <br />J.T <br />1. <br />NA\3 <br />Sample Result:. 9 <br />366 - 14 ©� <br />(* GASOLINE <br />1000 <br />100 <br />10 <br />10,000 <br />1000 <br />100 <br />r n h am <br />ALLOWABLE TPH LEVELS (PPM) <br />TPN <br />DIESEL <br />FOOTNOTES: ***If documented soil and/or ground water contamination is present, not complete the Lg ching potential <br />analysis. (i.e., site is currently on UGT Contamination List fo ound water.) <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 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 > Allowable Levels *Yes NoII P(� <br />1 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 T <br />CONCUR WITH STAFF RECOMMENDATION <br />FOR CLOSURE <br />YESI INOi <br />(REFERRED TO SITE MITIGATION FOR EVALUATION <br />YES NOI <br />DATE REFERRED / / <br />DATE CLOSURE <br />LETTER MAILEDI <br />NAME OF <br />EVALUATOR <br />EH 23 80 (UGTWKSHT)\5/90 <br />