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4 <br /> SAN JOAcutu 4Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> I, AWORKSHEET FOR SITE CLOSURE EVALUATION [OA <br /> 2..� <br /> NAME OF FACILITYt t~ S4iEEPS CODE <br /> TANK ID 52 <br /> ADDRESS & ,. I - 19q5 - <br /> TANK SIZE 30-0 FUEL TYPE C7 t u <br /> II. GENERAL SITE HISTORY <br /> is permit current? vas No Permit E - Facility Status Code Doc.Soit/GW Cont Yes <br /> Number of Tanks at facility Ape of Tanks(if available) Type of Tank Steel Fbrgt SngtEiaE <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No Fasted precision test ? Yes No if yes, give date(s) <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? <br /> Was repair done under Inspection? Yes No Were soil samplesanalyzed? Yes No BTXE TPH-G TPN-D PblEDB <br /> Type of failure/discharge catastrophic long-term leakage overfill other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA F TENTIAL ANALYSIS) <br /> Soft Samples Received Yes No Depth to Ground Water Ref/Year Average Annual Precipitation As 14 110-1 25 <br /> On-Site Wells) Yes No Number S type Irr Oom1 1t <br /> Pub <br /> S Score S Score S Score <br /> Distance to Wells) 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 ant <br /> Minimum Depth to groundwater from the Soil Sample (fast) (( L 0 3,100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None 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 system, water welts, ) Nona 9 Unknown Present <br /> Unique site features: Recharge area, coarse soft, nearby wells. At least More then <br /> xxxxxx Max one ax <br /> COLU14N TOTALS»>TOTAL POINTS <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or aor 41 - 48 pts 40 pts or less <br /> ,n B T X E B T X E <br /> !�j r> MAXIMUM ALLOWABLE B-T-X-E LEVELS t ) t 50 qal 50 .3 .3 1. 1. NA\3 <br /> Sample Result: INE 1 10010 <br /> MAXI ALL LE TPN LEVELS (PPM) <br /> TPI DIESEL 100 1000zi 100 <br /> FOOTNOTES: ***If ted soft end/or g water contamination is present, not c the Leaching potential <br /> currentlyanalysis. (i.e., site is currently an UST Contamination List or oil or ground 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 8TX3E are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> Vt. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX b E or TPN Concentrations > Allowable Levels *Yes No <br /> 2. Recommend Site Ctosure 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 CLOSURE YES NO RE TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / ! DATE CL LETTER NAILED ! <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />