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SAN 1OAr" ]LINTY PUBLIC HEALTH SERVICES/ENViRONMENTar•_'` iH DIVISION <br /> I, UGST WORKSHEET FOR SITE CLOSURE EVALUATI(D DATE 9 <br /> 1NAME OF FACILITYZEE SWEEPS COOEI / <br /> I <br /> IADORESSI3133 j'j TANK IO 9 - � g� Q `7 _ <br /> TANK SIZE �!bbO FUEL TYPE -_ �i Q Se-Q + 1�/J n Ffv*gjo1eS <br /> I1, GENERAL SITE HISTORY <br /> r** <br /> r <br /> Is permit current?IYes1x I Noi� IPermit 9 Facility'5tacus Code) Doc.SaiL/GW Cont Yes No <br /> jNumber of Tanks at facility IAge of Tanks(if available) iklTypeof tank Steel Fbrgll Sngi Dual <br /> IIT. TANK HISTORY <br /> ,l <br /> i <br /> Was Tank tested? Yesl No Failed precision test ?IYes No !1f yes, give date(s) <br /> !Was a repair made to the tank system? Yesl No If yes, what was repaired?! <br /> was repair done under inspection? Yes NoI IWere soil samoles analyzed? Yes; 11Nol BTXEI TPH-E ITPH-D IPWEDBI <br /> 1Type of failure/discharge) lcatastrophicl long-term leakages )overfill- 4Iunknowrtl lather: - <br /> IV. .REMOVAL HISTORY (ATTACH iNS?ECTiCN REPORT FOR SITE DETAILS/COLLECT DATA FOR, LEACHING POTENTIAL ANALYSIS) <br /> FSoi[ Samples Received Yes INoI !Depth to Ground Water! IRef/Year! ji; !Average Annual Precipitation A=11 1D-25 <br /> On-Site WeLI(s) Yes) Nol INumber & Type Frr Doml Pub) 'j <br /> S Score'. S Score S Score <br /> Distance [o We[l(s) from Tank ft; ft; ft C ii 10 pCS G 9 pts C 5 pts <br />! a if 0 if O if <br /> R condition R condition R condition <br /> V. Site Feature - Leaching Potential Analysis "c :his ser' E is met E is met <br /> i. ;Minimum Depth to groundwater tram the Soil Sample (feet) >100 I I51-100 25-50\1 <br /> !Fractures in subsurface (applies to foothills or mountain areas) I None I Unknown (Present <br /> .Average Annual Precipitation (inches) xxxxxx10 9 110-25 Ixxxxxxx 26-40\2 <br /> ::Man-made conduits which increase vertical migration <br /> - Unknown Presenof leachate (i.e. septic systems, water wells ponds) None t <br /> f <br /> 'Unique site features: Recharge area, coarse soil, nearby wells. i I At least More than <br /> xxxxxx .4one one one <br /> 1 i <br /> ?40 A)D <br /> f <br /> � QB 3,3COLUMN TOTALS>>>TOTAL POINTS + + <br /> Pi <br /> ;Sample Result: (3 T X OR E) RANGE OF TOTAL POINTS 49 pts:or more 41 - 48 pts 40 pts or Less <br /> a�E.5 <br /> ,-gip--T0, x��y, B T ' X E B T X E <br /> j MAXIMUM ALLOWABLE 3-3-X-c LEVELS (PPM) 1I 50I 50 50 .3 I.3 -1. 1:) NA\3 <br /> t��Sample Result: GASOLINE 1000 I 100 10 <br /> s t) MAXIMUM ALLOWABLE TPH LEVELS (PPM) ' <br /> = If 7 a TPH I DIESEL 10;000 41, 1000 I 100 <br /> !FOOTNOTES: "**If documented sail and/or ground Water contamination is present" thing potential <br /> R q bj 160 analysis. (i.e., site is currently an UGT Contamination List for sail 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 /> i \3 Levels for BTX&E are not applicable at a TPH cancentration of M,ppm (gasaline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are aTX & E or TPH Concentrations > Al[owable Levels I*YesNa I if <br /> Xlf� <br /> 2. Recommend Site Closure Yesl No If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR f <br /> i <br /> CONCUR WITH STAFF RECCMMENOATION FOR CLOSURE IYES I NO (REFERRED TO SITE'MITIGATION FOR EVALUATION�YESI ' NOj I <br /> DATE REFERRED( (DATE CLOSURE LITTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EA 23 30 (UGTUXSHT)\5/90 <br /> i' <br />