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SAN JOAWJIM <br />I. <br />MAKE OF FACILITY <br />ADDRESS <br />TANK SIZE FUEL TYPE <br />II. GENERAL SITE HISTORY <br />I <br />PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAIn" 'DIVISION <br />WORKSHEET FOR SITE CLOSURE EVALUATION ` DATE <br />, LLL <br />SEEPS CODE <br />TANK ID # <br />A 19b r ®0(1721 <br />Is permit. current? <br />Yes <br />No <br />I aafted <br />Permit # <br />Yes <br />Facility Status Code <br />No <br />Doc.Soil/GW Cont <br />Yes <br />10-25 <br />No <br />Yes Mo <br />Number of Tanks at facility <br />yes, what_was repaired? <br />Ape of Tanks(if available) <br />Was repair done under inspection? <br />Type of Tank <br />Steel <br />IVDom <br />Fbrgt <br />Putt <br />sngl <br />Dust <br />TPN -G <br />III . TANK H I STORY . I I/ <br />Was Tank tested? <br />Yes <br />No <br />I aafted <br />precision test <br />Yes <br />; <br />No <br />An <br />If yes, give date(s) <br />10-25 <br />was a repair made to the tank system? <br />Yes Mo <br />V1If <br />yes, what_was repaired? <br />Was repair done under inspection? <br />Yes <br />No <br />IVDom <br />Were soil samples analyzed? Yes <br />Putt <br />No <br />BTXE <br />TPN -G <br />TPH-D <br />Pb/E06 <br />Type of failure/disdtaroa <br />catastrophic <br />tang -term leakage <br />overfill <br />I lunknownIother: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />Soft Samples Received Y!p <br />YES <br />No <br />Depth to Ground Wate <br />Ref/Year <br />; <br />Average Annual Precipitation <br />An <br />14 <br />10-25 <br />Orn -Site Wett(s)Yes <br />NAME OF <br />EVALUATOR <br />No <br />Number & Type <br />Irr <br />IVDom <br />Putt <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 WeLt(s) from Tank <br />ft,- ft; ft <br />0 <br />R <br />if <br />condition <br />0 <br />R <br />if <br />condition <br />0 <br />R <br />if <br />condition <br />V. Site Feature - Leaching Potential Analysis <br />E <br />is met <br />E <br />is met <br />E <br />is met <br />Minimum Depth to groundwater from the Soft Sample (feet) <br />3"100 <br />51-100 <br />25-50\1 <br />Fractures in subsurface (applies to foothills or mountain areas) <br />None <br />Unknown <br />Present <br />Average Arraiat Precipitation (inches) <br />xxxx=1 <br /><10 <br />9 <br />10.25 <br />xxxxxxx <br />25-40\2 <br />Man -Made conduits which increase vertical migration <br />of leachate (i.e., septic systems, water wells, ) <br />MGM <br />UnkrArdin <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 />ane <br />COLUMN TOTALS3"3"3"TOTAL POINTS <br />Sample Result: (B T X OR E) <br />RANGE OF TOTAL POINTS <br />49 pts or more <br />41 48 pis <br />40 pts or less <br />X <br />E <br />B <br />XMAXIMUM <br />E E <br />ALLOWABLE B-T-X•E LEVELS (PPM) <br />1 <br />FsTo <br />50 <br />50 <br />.3 J.T <br />3 <br />i. <br />MA\3 <br />Sample Result: <br />GASOLINE <br />1000 <br />100 <br />10 <br />MAXIMUM ALLOUULE TPH LEVELS (PPM) <br />10,000 <br />1000 <br />100 <br />TPN <br />DIESEL <br />FOOTNOTES: ***If documented soft and/or ground eater contamination is present, do not complete the teaching potential <br />analysis. (i.e., site is currently an UGT Contamination List for soft or grand water.) <br />\1 If depth is 3" 5 ft. and < 25 ft., score 0 points. If depth �=5 ft., do not use table. <br />\2 If precipitation is 3" 40 inches, score 0 points. <br />\3 Levels for 8TX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm Cdiesel). <br />VI. STAFF RE ATIOM/CONt3=IOM <br />1. Are BTX & E or TPH Concentrations a Allowable Levels *Yes No <br />2. Recommend Site Ctosure Yes No if Yes, Refer to Site Mitigation for Evatuati <br />VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br />M <br />CONCUR WITH STAFF RECOMMELMATION FOR CLOSURE <br />YES <br />NO <br />REFERRED TO SITE MITIGATION FOR EVALUATION <br />YES NO <br />DATE REFERRED <br />/ / <br />DATE CLOSURE LETTER MAILED= <br />NAME OF <br />EVALUATOR <br />EH 23 80 (UGTWKSHT)\5/90 0 <br />