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SAN IQ RUNTY PUBLIC HEALTH SERVICES/ENVIRONMENT TH DIVISION � <br /> I. �/ UGST WORKSHEET FOR SITE CLOSURE EVALUAI DATE <br /> !NAME OF FACILITY SWEEPS CODE <br /> 1ADORESS ,313-3 ' -r- , I TANK IO 0 3 l —3 <br /> !TANK SIZE! �FUEL TYPE( WA6re, Q Gpi <br /> 'r <br /> II. GENERAL SITE HISTORY <br /> ,Is permit current? Yes No (Permit R - Facility Status Code) Doc.Soil/GW Cont Yes Nol <br /> jNumber of Tanks at facility) Age of Tanks(if available) Type of TanklSteeL Fbrgi Sngl Dua[{i <br /> III. TANK HISTORY <br /> was Tank tested?!Yes No Failed precision test ?ITes No If.yes, give dare(s) / <br /> 'Was a repair made to the tank syStem71Yes No If yes, what was repaired7 <br /> lUas repair done under inspection?1Yesl Not were soil samples ana[yzed?' Yes! JNo1 BTXE1 TPH-GI (TPH-Df �Pb/ED81 <br /> e I <br /> ;Type of failure/discharge catastrophic (long-term Leakagei ioverfill ;R unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> c <br /> e !Soil Samples Received Yes No (Depth to Ground water Ref/Year Average Anna€ Precipitation A=114, 110-25 <br /> r <br /> On-Site Wells) Yesl Na Numoer b Type) Irrl Dan Pub <br /> S Scare 5 Score S Score <br /> joistance to We€l(s) from Tank ft; ft; ft C 1� 16 pts C 9 pts C 5 pts <br /> a if a if 0 if <br /> R j' condition R conditions R condition <br /> EV. Site Feature - Leaching Potential Analysis _ a}lis met E is met I E is met <br /> FMinimum Depth to groundwater from the Soil Sample (feet) w >100' 1 151-100 I i 25-50\1 <br /> i <br /> Fractures in subsurface (applies to foothills or mountain areas) is 4one I I Unknown Present <br /> .Average Annual Precipitation (inches) xx=x x <10 9 10-25 jxxxxxxx 25-40\2 <br /> !Man-Made conduits which increase vertical migration <br /> of Leachate (i.e., septic systems, water wells, ponds) b I 'Ione I Unknown I Present <br /> !Unique site features: Recharge area, coarse soil, nearby wells. 'p At least More than <br /> ixxxxxx 4one I one! one <br /> COLUMN TOTALS»>TOTAL POINTS <br /> f Sample •Result: (B T X OR °) RANGE OF TOTAL POINTS 49 pts or more 41 - 4a pts I 40 pts or less <br /> ; ,D0` . 00 <br /> x alMAXIMUM ALLOWABLE B-T-X-_ LEVELS (PPM) 1 501 501 50 .3 I.3 X1.1 E. NA\3 <br /> SampEe Result: <br /> !GASOLINE 1000 1 100 10 <br /> MAXIMUM ALLOWABLETPH LEVELS (PPM) <br /> TPH DIESEL 16,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is 'present, donaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for sail or greund water.) <br /> \1 If depth is > 5 ft. and < 25 ft., scare 0 points. If depth <=5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (dieseE). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No <br /> 2. Recommend site Closure Yes Na *[f Yes, Refer to Site Mitigation for Evaluation <br /> VI1. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR CC Q�[¢(u"'-et— <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSUREIYE5 IN01 (REFERRED To SITE MITIGATICN FOR EVALUATION YES NOI <br /> DATE RE'sFERREDI / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> -cH 23 80 (UGTWKSHT)\5/90 <br />