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SF- L SAN d0A0U IN C•"-"- PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTm `VIS <br /> ION <br /> I. XRKSHEET FOR SITE CLOSURE EVALUATION -1 DATE / <br /> NAME OF FACILITY "/nu � �` D�. ` SWEEPS CODE �9 C <br /> ADDRESS TANK ID 0 <br /> TANK SIZE �---D FUEL TYPE W�D <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? Yes No Permit # - Facility Status Code Doc.Soi L/GW Cont Yes No <br /> Number of Tanks at facility Age of Tanke(if available) Type of Tank Steel Fbrgl Sl Dual <br /> Ill. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test ? Yes No If yes, give date(s) <br /> Was a repair made to the tank system? Yes Rol If yes, what was repaired? <br /> Was repair done under inspection? Yes No Were soil samples anaLyied? Yes No BTXE TPN-G TPH-D 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 5V Ref/Year Oi�_ ; Average Annual Precipitation A=114 10-25 <br /> On-Site WeLL(s) Yes No Number & Type Irr Dom Pub <br /> S Scare 5 Score S Scare <br /> Distance to WeLL(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 Potential Analysis E is met E is met E is met <br /> Minimum Depth to groundwater from the Soil Sade (feet) 1 -1013 51-100 25-50\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 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: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 1 - 48 pts 40 pts or less <br /> 7'N.0 .a• ry rvyOp( <br /> _ B T % E B T % E <br /> 'a_p�'/'"`5�"'a MAXIMUM ALLOWABLE B-T-%-E.LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> -7"W-P MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> _TPH -40 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 grand 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 8TX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION -=-1 <br /> 1. Are 8T% & E or TPH Concentrations > Allowable Levels -yes No L/y <br /> 2. Recommend Site Closure Yes No If Yes, Refer to Site Mitigation for Evaluation H� / W� <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/ ENIOR rl`r `♦rOh <br /> flY� <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER HAILED <br /> NAME OF <br /> EVALUATOR <br /> EN 23 80 (UGTWKSHT)\5/90 "'•` ""1)4yl`h <br />