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SAN ICACUiN COUNTY LIC HEALTH SERVICES/ENVIRONMENTAL HEALTH D""SIGN <br /> UGS KSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY Z'>v f C cD SWEEPS CODE 7 . <br /> I <br /> DRESS L/{YS i ,� c. «s TANK ID NK SIZE FUEL TYPE <br /> 1. GEVERAL SITE HISTORY <br /> Is permit current? Yes No Permit ft - Facitity Status Code Doc.SoiL/GV Cant Yes No <br /> Number of Tanks at facility Age of Tanks(if avaiLabLe) Type of Tank Steel Fbrgl SngL Dual <br /> Ii. TANK 4ISTORY <br /> Was Tank tested? Yes No Failed precision test 7 Yes Ho If yes, give date(s) <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? <br /> Was repair done under inspection? Yes No Vere soil sampLes analyzed? Yes No STXE TPH-G TPH-0 Pb/EDB <br /> Type of failure/discharge catastrophic long-term Leakage overfill unknown other: <br /> V. REMCVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samptes Received Yes No Depth to Ground Vater Ref/Year ; Average Annual Precipitation A= 14 10-25 <br /> On-Site WeLL(s) Yes No Number $ Type Irr Dom Pub <br /> S Score S Score S Score <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 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothitts or mountain areas) None Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 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 + + <br /> Sample Result! (13 T X OR E) RANGE Of TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or Less <br /> B r x E B x E <br /> MAXIMUMALLOWABLEALLOSLE B-T-X-E LEVELS (PPM) 1 505050 .3 J.T <br /> 3 1. 1. NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> 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 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 BTXBE are not applicable at a TPH 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 <br /> 2. Recommend Site Closure Tes No *If Yes, Refer to Site Mitigation for EvaLuation <br /> VII. REVIEW EVALUATION - TO 3E COMPLETED BY A SUPERVISOR/SENIOR <br /> CCNCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE 141TIGATICN FOR EVALUATION YES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 aG (UGTWKSHT)\5/90 <br />