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SAN b%, Ill COUNTY PUBLIC HEALTH SERVICES/ENVIRONML,,...L HEALTH DIVISION p <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE 11075—Z 0 <br /> AME OF FACILITY <br /> WEEPS CODE /U <br /> DRESS o <br /> G <br /> TANK ID r 39 <br /> [ARK 512E t1El TYPE <br /> I1. GENERAL SITE HISTORY <br /> n <br /> Is Permit current7 es o Brant e -pp14 stili ty Status Code Qj a,Soi /GW Cant es o <br /> unbar of -37 <br /> Tanks at facility pe of Tani available) t <br /> / 2 ype'of TaNt teal brgl rapt Dual <br /> - 111. TANK HISTORY <br /> as Tank tested7 if es l• o ailed precision test 7 Ifes 0 If yes, give date(s) <br /> Jas a repair mode to the tank systam? as No f yes, what was repsired7 <br /> Jas repair done unler inspec Clan? as o ere soil carp les Una lyted7 es o rT%E fPH-G IFPH•D b/EDD <br /> fyPe of failure/discharge atos trophic long-term leakage verf ill mown then: <br /> IV. REMOVAL HISTORY (ATTACH INSP TION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es o epth to Ground Water -5n of/Year ver age Annual Precipitation ii. 4 0-25 <br /> D11'Site Well(s) es ' 0 unber 8 Type Orr an ub <br /> istance to Wells) from Tank ft; ft. S Score S Score S 3core <br /> ft C 10 pts c 9 pts C - pts <br /> 0 it 0 if 0 if <br /> V. Site feature - Leaching Potential Anal sts R oditnon R condition k onditim <br /> Y E is met E is na:E E is ax:c <br /> i ninon Depth to groudwater tram the Sol <br /> l Saiple (feet) >100 51•100 25•SOL <br /> 7 <br /> raccures in subsurface (applies to foothills or nnun[aln areae) j 0 None Unknown resent <br /> verage Annual Precipitation (inches) xxxx <10 9 10-25 xxxxxx 26.401 <br /> 'an-made Cetl(i.e. which Inby Use Vertical migration <br /> f Leachate (i.e., septic systems, Macer wells, ponds) None Unknown resent <br /> ique site features: Recharge area, coarse soil, nearby wells. <br /> • At least ore than <br /> xxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS <br /> a'ample Result: (B 1 X OR E) RANGE OF TOTAL POINTS 9 pts or aarn 41 - 40 pts 40 pts or/ less <br /> e4dol- 58X <br /> yr� H T x E H T x E <br /> MAXIMUM ALLOWABLE B-T-X•E LEVELS (PPM) 1 50 50 50 <br /> Sample Result: ASOLINE 1000 100 )p <br /> G IMJN ALLOWABLE <br /> TPH TPH LEVELS (PPM) <br /> OE SEL 10,000 1000 100 <br /> OOTNOTES: 0.61} do;uoented soil and/or ground water contamination is present, do not ca plete the leaching potential <br /> analysis. (i,e-, site is currently on UGT Contaainatlon Lis[ for soil or ground water.) <br /> �1 If depth Is > 5 ft. and c 25 It., score 0 points. if depth <=5 ft., do not use table. <br /> 1 If precipitation Is > 60 inches, score 0 points. <br /> L Levels for BTXLE are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECMIENDATI ON/CONCWSION n �� 7 �L/, <br /> 1. Are BTX i E or TPR Concentrations > At <br /> lowsble Levels Yes o NOr pf` f0-2rJ�n `t91/Yi et S4, <br /> 2. Recommend Site Closure as 0 If Yes, Refer to Site Mitigation for Evaluation ctiGno �m �ri ` <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SLiPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES \ ' O EFEkRED TO SITE MITIGATION FOR EVALUATJpt( ES 0 <br /> ATE REFERRED Q / v ATE LOSURE IETTER AILED <br /> AME OF 4. <br /> `VALUATOR - <br /> Ell 23 00 (UGIWKSHT)\5/90 `^^ <br />