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SAH JOAOUIN CUL . BLIC HEALTH SERVICES/ENVIRCNMENTAL HEALT 1SICK <br /> a t UGST WCStKSHEET FCR SITE CLOSURE EVALWTION !DATE# <br /> NAME OF FACILITY Sk7 rpS CCK1E <br /> IADORESS; -�3- 1 <br /> ` .i. i""t { TANK I O 8 <br /> TANK SIZE! I CC(:) IFUEL TYPE (,6_0 � <br /> II. GENERAL SITE H[STORY <br /> Is permit Current? Yes Ho Permit Facility Status Codel Doc.SoiL/GW Cont Yes No <br />{ Number of Tanks at facility Age.of Tanks(if available) Type of Tank Steel Fbrgl SngL Dual <br /> III- TANK HISTORY ;{ <br /> Was Tank tested? Yes ✓ No Failed precision test ? Yes No If Yes) give date(s) <br /> i II <br /> Was a repair made to the tank system? Yes No [f yes, what was repaired? <br /> j Was repair done under inspection? Yes INo Were soil samples analyzed? Yes No BTXE ITPH-G TPH-0 Pb/EDB <br /> Type of failure/discharge catastrophic Long-term leakage overfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Ground Water Ref/Year l Average Annual Precipitation A= 14 10-25 <br /> On-Site WeLL(s) Yes No Number & Type Irr Dom Pub r <br /> P <br /> S Score S Score S. Score <br /> Distance to WeIL(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if I; 0 if 0 if <br /> R condition R condition R condition <br /> V. Site Feature - Leaching Potential Analysis E is rnet E is met E is met <br />. .j <br /> Minimum Depth to groundwater from the Soil, Sample (feet) >100 51-300 25-50\1 1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx -4 <br /> p 25 0 2 <br /> Man-Made conduits which increase vertical migration I' <br /> l <br /> of leachate (i.e., septic systems, water wells, ponds) Norte Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> xxxxxx Norte one one <br /> COLUMN TOTALS>>TOTAL POINTS + + = r <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pis 40 pts or less <br /> B T XF15 <br /> B JT X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 500 .3 .3 1. 1. NA\3 <br /> Sample Result: GASOLINE 1000 1j 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH DIESEL 10,000I 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. ;f <br /> \3 Levels for BTX&E are not applicable at a TAH concentration of;;10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No R <br /> 2. Recommend Site Closure Yes No If Yes, Refer to Site Mitigation for;Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR �I <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NOREFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 SO (UGTWKSHT)\5/90 <br /> 1 _ <br />