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SAN JOAOUI ?Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL DIVISION DATE <br /> I JGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> NAME OF FACILITY G I� Qxz: Mfr o+ E-<.A COO? 'Y AlleD SWEEPS CODE 4 )_+49 } <br /> ADDRESS TANK ID # 39 JySQo Z <br /> TANK SIZE 1ptippp FUEL TYPE D <br /> II. GENERAL SITE HISTORY <br /> **w <br /> Is permit current? Yes No Permit # F cility Status Code Q Doc.Soil/GW Cont YesF No <br /> Number of Tanks at facility3 Age of Tanks(if available) Type of Tank Steel Fbrgi Sngl Dual <br /> Ill. TANK HISTORY <br /> i <br /> Was Tank tested? Yes No Failed .precision test ? Yes No If yes, give dates) <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? <br /> i <br /> Was repair done under inspection? Yes No Were soil samples a lyzed? Yes No BTX TPH-G TPN-D Pb/EDB <br /> Type of failure/discharge catastrophic Eong-term leakage ov dill unknown other: j <br /> IV_ REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT ATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Ground Water Ref/Year Average Annual Precipitation A� 14 10-25 <br /> On-Site WeLL(s) Yes No Number & Type Irr Dam Pub <br /> S Score S Score S Scare <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 met <br /> minimum Depth to groundwater from the Soil Sample (feet) >100 151-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) f 0 None Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 Ixxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) None Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> xxxxxx None one one <br /> COLUMN TOTALS>>TOTAL POINTS ZO + 6 + C _ S v <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POIN S 49 pts or more 41 48 pts 40 pts or less <br /> B T X E 8 JT X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PP ) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: �Tg GASOLINE 1000 100 10� MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> b;'SZ— 4"t- 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 con entration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > ALLowable Leveis *Yes No <br /> 2. Recommend Site Closure Yes No if Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISORS IOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YE NO IREFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MA LED / / <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />