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ITY PUBLIC <br /> EALTH <br /> SAN 10A0E"NWW uGST WORKSHEET FOR S�7EICLOSUREIEVALUAFI Ta..� DIVISIONDATE <br /> NAME OF FACILITY - SWEEPS CODE X/ <br /> ADDRESS ,1 t � '' TANK 10 - `3 —6-3 <br /> X13 <br /> TANK SIZE FUEL TYPE <br /> 1I. GENERAL SITE HISTORY ^� <br /> Is permit current? Yes No Permits - Facility Status Code (� ' lDac.Soil/GU Cant Yes No <br /> Number of Tanks at facility Age of Tanks(if available)13 Type of Tank Steel lFbrgll lSngL Dual <br /> 111. TANK HISTORY <br /> Was Tank tested? Yes XINal failed precision test ? Yes No If yes, give date(s)1 <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 sail samples analyzed? Yes lNo BTXE !ITPH-GTPH-0 Pb/EDB <br /> Type of failure/discharge catastrophic Long-term Leakage loverfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes ko DeQth to Ground Water56 Ref/Year �'� Average Annual Precipitation A=114 10-25 <br /> On-Site WeLL(s) Yes No Number & Typel Irr Dom Pub !u <br /> i <br /> S Score S Score 5 Score <br /> Distance to WeLI(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 Potentia( Analysis E is met E is met E is met <br /> IMinimum Oepth to groundwater from the Soil Sample (feet) 50— +>100 51-100 I �� 25-50\1 <br /> Fractures in subsurface (applies to foothiLLs or mountain areas) !,None Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx <br /> <10 1 4 1 10-25 xxxxxxxl 26-40\2 <br /> f <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wel(s, ponds) None Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. �� I I At least More than <br /> x�cxxx (None If one one <br /> 7K#.3 vl k,+G N i c i !t_ =& I CAA u+�n tat 76 <br /> C��i YIL(IsAv� OLUMN TOTALS>,>TQ7AL POINTS <br /> Sample Result: (S T X OR E) RANGE OF TOTAL POINTS 49 pts or more, I 41 - 48 pts 40 pts or less <br /> 8 T !X E 8 T X E <br /> (1 <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) it SO l50 50 .3 .3 11. 1. NA\3 <br /> SamoLe Re ult X= •a� GASOLINE 1000 100 10 <br /> 7' T 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 na ete 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. ;a <br /> \3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm, (ngasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION Oh � <br /> � 3I$ t?i T (RxQ$ a � �. 605 <br /> Te sfe ct a*d.35 <br /> 1. Are BTX & E or TPH Concentrations > ALLowabte LeveL5 *Yes No 1 <br /> 2. Recommend Site Closure Yes No If Yes, Refer to.Site Mitfgation,for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NOI REFERRED TO SITE MITIGATION FOR EVALUATION YESI V N01 <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILEDI <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />