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SAN ,10AOU COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL iLTH DIVISION <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATIO%,,e DATE <br /> NAME OF FArrC��ILITY 11��� II�� SWEEPS CODE <br /> Z ADDRESS .��U �� Gl Vl,.l �-'�l(� TANK ID # <br /> TANK SIZE /k,CX_y D FUEL `,�(CSGI <br /> It. GENERAL SITE HISTORY <br /> Is permit current? Yes No Permit # - Facility Status Code Doc.Soi L/GW Cont as No <br /> Number of Tanks at facility Age of Tanks(if available) (Type of Tank Steel Fbrgl Sngl Dual <br /> 111. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test 7 Yes No If yes, give date(s) <br /> Was a repair made to the tank system? Yes No Iif yes, what was repaired? <br /> Was repair done under inspection? Yes No Were soil samples analyzed? Yes No BTXEI TPH-GI I <br /> 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 Average Annual Precipitation A=114 10-25 <br /> On-Site Wet L(s) Yes Na Number & Type Irr Dam Puh <br /> S Score S ScareS Score <br /> Distance to We(t(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 candition 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 I51-100 I 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx <10 1 9 110-25 xxxxxxxl 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 /> xx)o= None one one <br /> COLUMN TOTALS>>>TOTAL POINTS + + - <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts I 40 pts or Less <br /> 81 T % I E 8T X E <br /> 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 /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH DIESEL 10,000 1000 - I 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 BTX&E 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 I Yes INoI If 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 YES NOI REFERRED TO SITE MITIGATION FOR EVALUATION YESI NO <br /> DATE REFERRED / / (DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />