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SAN )OAOi^w COUNTY PUBLIC HEALTH SERVICES/ENVIRONMEHTA' 'c.ALTH DIVISIDN <br /> I. UGST WORKSHEET FOR SITE CLOSURE EVALUATI DATE -7 <br /> NAME OF FACILITYU , (SWEEPS CODE( 3 ' S <br /> AOORESSI 3 )�l AS G 1 TANK ID 3 - <br /> i <br /> TANK SIZE 16b&D FUEL TYPE <br /> 7 <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? Yes No IPenmit Al - (Facility Status Cade Doc.SoiL/GW Contl Yes INoI <br /> (Number of Tanks at facility IAge of Tanks(if available)) (Type of Tank Steell IFbrgtI ISngl Dual <br /> 111. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test ITY`es No If yes, give date(s) <br /> i <br /> Was a repair .made to the tank system?IYes No If yes, what was repaired?( <br /> was repair done under inspection? Yes NoI Were soil samples analyzed? Yesl INoI BTXE (TPH-GI ITPH-DI IPb/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 /> SciL Samples Received lYes, No Depth to Ground Water) IRef/Yearl Average Annual Precipitation A=I 14 I10-Z5 <br /> On-Site wetL(s)I Yes Na Number & Type Irr (Dan Pub <br /> S Scare <br /> ID istance to Well(s) from Tank ft; S Score S Score <br /> f!; ft C 10 pts C 9 pts C 5 pis <br /> 0 if 0 if 0 if <br /> R condition R condition R cactiti an <br /> iV. Site feature - Leaching Potential Analysis - is as E is met E is mei <br /> (Mini" Depth to groundwater from the SoiL Sample (feet) j C _ I >100 I 51-100 I 25-50\1 <br /> Frac:ures in subsurface (applies to foothills or mountain areas) I I None Unknown (Present <br /> ,Average AnnuaL Precipitation (inches) xxxxxxl <la I 9 1 10-25 jxxxxxxx Z6-40\2 <br /> iMan-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) I None Unknown I Present <br /> (Unique site features: Recharge area, coarse soiL, nearby wells. I I At least More than <br /> xxxmc None <br /> on <br /> one <br /> COLUMN TOTALS»>TOTAL POINTS <br /> Sample Result: (S TX OR E) RANGE OF iOTAL POINTS 49 pts or more I 41 - 48 pts 40 pts or Less <br /> S'S I L>G.�. - 6 I 4// a i X E B T % <br /> ti)!� <br /> MAXIMUM ALLOWABLE a-r-x-E LEVELS (PPM) 1 SOI 50I 50 I .3 .3 I_I iF. NA\3 <br /> Sample Result: /' ID GASOLINE 1000 I 100 10 <br /> SID (7�-�� � M MAXIMM ALLOWABLE TPH LEVELS (PPM) <br /> TPH 1�1 DIESEL 10,000 I 100 I 100 <br /> FOOTNOTES: —if documented soil and/or ground water contamination is present, do not complete the Leaching potentialre <br /> atysis. (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 <- 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 TPN concentration of 10 ppm (gasoline) or 100 ppm (dieset). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels `Yes) INoI <br /> 2. Recommend Site Closure Yes7N-0777-yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YESI NO IREFERRED i0 SITE MITIGATION FOR EVALUATIONITESI INO <br /> DATE REFERRED / / (DATE CLOSURE LETTER MAILED / / I <br /> NAME OF <br /> EVALUATOR <br /> 2H 23 80 (UGTWKSHT)\5/90 <br />