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VSAN JOAOUlh1 LINTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL Ht-r.TH DIVISION r Y <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE I a—(O <br /> AME OF FACILITY G r' r WEEPS CODE U <br /> DDRESSl O S- (�[i ( ANK ID # <br /> TANKcjr <br /> SIZEff4jg UEL TYPE <br /> II. GENERAL SITE XISTORY <br /> Is permit current? es o ermit N Facility Status Code oc.Soil/GW Cont (FSEUI <br /> uNter of Tanks at facility ge of Tanks(if available) IType of Tank test IFbr9l I Isn9t I Dual <br /> 111. TANK HISTORY <br /> as Tank tested? es o ailed precision test ? as o If yes, give date(s) <br /> as a repair made to the tank system? es No 11f yes, what Was repaired? <br /> ns repair done under inspection? es 1 40 ere soil samples analyzed? Fas io I TXE PH•G PH-D b/EDB <br /> Type of failure/discharge ate trophic long-term leakage verfill nknown I lother: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es o epth to Ground Water of/Year verage Annual Precipitation = 4 10-25 <br /> )n-Site Wells) es o umber 8 Type Irr I om I ub <br /> S core S Score S 3core <br /> istance 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 ondition R conditI on R ondition <br /> Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1.100 25.50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) p None Unknown resent <br /> verage Annual Precipitation (inches) xxxxx <10 9 10.25 xxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> i leachate (i.e., septic systems, water wells, ponds) 'l None Unknown resent <br /> Inique site features: Recharge area, coarsesoil nearby wells. At least ore than <br /> \ w� xxxxx None I �y^' one gone <br /> COLUMN TOTALS»)TOTAL POINTS + ( U + _I <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> ND a.t� .c S- .2 PFm` iL <br /> g_ 'agB T X E B T X E <br /> MAXIMUM ALLOWABLE B•T•X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: ASOLINE 1000 100 10 <br /> NP Of to Py,�TPH III AXIMUM ALLOWABLE TPH LEVELS (PPM) IESEL 1 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not wiTlete t e iFaching 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 /> I. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure IYes o If Yes, Refer to Site Mitigation for Evaluation <br /> Vtl. REVIEW EVALUATION • TO BE CC14PLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME Of <br /> .VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />