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SAN JOAGUtN cmgMPUBLIC HEALTH SERVICESIENVIRONMENTAL HEALT` VISION <br /> I. WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACtLITY _ SWEEPS COOS <br /> ADDRESS TANK IO g - <br /> TANK SIZE FUEL TYPE Ll <br /> II. GENERAL SITE HM&Y <br /> eee <br /> Is permit current? Yes No Permit !1 - Facility Status Code Doc.Soit/GW Cant Yes No <br /> Number of Tanks at f itity Age of Tanks(if available) Type of Tank Lsteek Fbrgt Sngt Duat <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test 1 Yes No If yes, give dete(s) <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? I f�-pip-0-1 <br /> Was repair order inspection? Yes jua Were soil samples analyzed? Yes No STXE TPH-G TPH-0 Pb/EDB <br /> Type of failure/discharge catastrophic tong-term leakage overfitl unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soft Samples Received Yes NO Depth to Ground Water Ref/Year Average Amust Precipitation A= 14 10-25 <br /> On-Site WeLL(S) Yes No lNumber A Type Irr Dao Ptd <br /> S Score S Score S Score <br /> Distance to Wett(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 mat E is wet E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet) >1(O 51.100 25-50\1 <br /> Fractures In subsurface (applies to foothitts or mountain areas) None Unknown Present <br /> Average ArvxmL Precipitation (inches) xxxxxx <10 9 10-25 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of Leachate (i.e., septic systems, water welts, ) Mane Urduwwn Present <br /> Unique site features: Recharge area, coarse soil, nearby watts. At Least More than <br /> Nona ane ase <br /> COLUMN TOTALV>210TAL POINTS • _ <br /> Sampte Result: (3 T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 4$ pts 40 pct or Less <br /> r5loX50 <br /> E 3 T X E <br /> MAXIMM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 .3 .3 1. 1. NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> MAXIMIAI ALL LE TPR LEVELS (PPM) <br /> TPN DIESEL 10,000 1000 100 <br /> FOOTNOTES: *self documented snit and/or ground water contamination is present, do not comptate 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, scare 0 points. <br /> \3 Levels for BTXIE are not appticabis at a TPN concentration of 10 ppm (gasoline) or 100 ppm (dieset). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 4 E or TPN Concentrations > Allowable Levels *Yes Mal I <br /> 2. Recommend Site Closure Yes No If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BT A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECCHMENDATION FOR CLOSURE YES NORE TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / ! DATE CLOSURE LETTER MARL DD / / <br /> NAME OF <br /> EVALUATCR <br /> EH 23 30 (UGTWKSHT)\5/90 <br />