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>? SAN JOAt1UIN TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH. DIVISION <br /> $' WORKSHEET FOR SITE CLOSURE EVALUATION DATE co -_7_ <br /> OF FACILITY ` SWEEPS CODE <br /> . � <br /> TRESS Al, TANK ID # I ®- <br /> s (ANK SIZE FUEL TYPE <br /> II. GENERAL SIA HI ORY <br /> Is permit current? Yes No Permit # - Facility Status Code Doc.Soit/GW Cont Yes No <br /> Number of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Duat <br /> III. TANK HISTORY <br /> Was Tank tested?_ Yes _ No __ Fa Med-precision_test? Yes ___ _ No __-- if yes, �ive_date(s)_ O_/ __/ , <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? Y- [. <br /> Was repair done under inspection? YesNo Were soil samples analyzed? Yes a No BTXE TPH-G TPH-D Pb/EDB <br /> Type of failure/discharge catastrophic long-term leakage overfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Ground WaterL Ref/Year ; Average Annual Precipitation A= 14 10-25 <br /> On-Site Wetl(s) Yes No Number & Type Irr Dom Pub <br /> S Score S Score S Score <br /> Distance to Welt(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 /> Minimum Depth to groundwater from the Soil Sample (feet) >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown 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 systems, water wells, ) Nam Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby welts. At least More than <br /> xxxxxx None one one <br /> COLUMN TOTALS»),TOTAL POINTS + + _ <br /> Sample Result: (S T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> OT's <br /> X E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM)00 50 50 .3 .3 1. 1. <br /> NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH DIESEL 10,000 1000 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 on UGT Contamination List for soil 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 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 TPN Concentrations > Allowable levels *Yes No <br /> 2. Recommend Site Closure Yes Ll 1 No *If Yes, Refer to Site Mitigation for Evaluation t <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR /7' <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED / I <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />