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SAN .1CAOU- MMTY PUBLIC HEALTH SERVICES/ENVIRCNMENTAL TH DIVISION <br /> • ti UGST WORKSHEET FOR SITE CLOSURE c/ALUATICM� DATE( 5-/ -3._ C3� <br /> !NAME OF FACILITY SHEEoS CODEI � —a 0 <br /> IADDRESS� JAG r TANK ID <br /> J - <br /> !TANK SIZE( /\ 1FUEL TYPE( �S'�� V C <br /> '.l. GENERAL SITE HISTORY I <br /> its permit current?1Yes INo IPerait N (Facility Status Cade) IDcc.SoiL/GW Cant Yesl INo( <br /> Nunder of Tanks at facility) (Age of Tanks(if avaitaole)I (Type of Tankl Steel FbrgLI ISngtK Duall <br /> [I!. IANK HISTORY <br /> Was Tank tested?IYes INo (Failed precision test ?I Yes1 INoI IIf yes, give cate(s)I <br /> was a repair made to the tank syszeu21Yes1 No If yes, what vas repaired?( <br /> juas repair done under inspection?IYes 1 INoI (Vere soil samples analyzeo?I YesI INoI BTXE1 (TPN-GI (TPN-01 IPb/EDSI I <br /> Type of Failure/discharges )catastrophicI hang-cern leakage IoverfiLLInI Iother: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Recei vedlYesl INa1 Depth to Ground Waterli l()IRef/Yearl0/ (Average AnruiL Precipitation)A=114 110-25 <br /> lOn-Site Well(s)IYes INoI 1Nunaer 3 Type 11rrI (Dam IPto1 <br /> S Scare S Score S Scare <br /> Distance to Wei.L(s) frau Tank ft; ft; ft C 10 pts C 9 pts C 5 pis <br /> G if 0 if 0 if <br /> R condition t condition R condition <br /> V. Site Feature - Leaching Potential Analysis GE is .aet = is met is met <br /> IMinimm Depth m groundwater From the Soil Sample (."t) I 'D.. f _ 1 'ICO I 151-100 125-50\l <br /> (Fractures in subsurface (acplies to Foothills or mountain areas) I I None 1 1 Unknown I (Present <br /> (Average Annual Precipitation (inches) Ixxxxxxl 110 1 9 110-ZS Ixxxxxxxl 26-40\2 <br /> IMan-Made conduits which increase vertical migration R <br /> of leachate (i.e., septic systeam, water wells, ponds) .Hone I ! Unknow Present <br /> Unique site features: Recharge ares, crane soil, nearby vel Ls. I Ac least) More than <br /> xx:000C None `-� ane one <br /> COLUMN TOTALS9»TOTAL POINTS 1101 <br /> Saimle Result: (B T X OR E) RANGE OF TOTAL POINTS 149 pts or .Wore I 41 - 48 pts, I 40 pts or less I <br /> MAXIMUM ALLOWABLE 3-T-z-E LEVELS (PPM) 3 50 501 50 .3 .S 11. 1. NA\3 <br /> S le Result: GASOLINE 1000 1 100 I 10 <br /> r )W !I ' 1,100 MAXIMA WA TPN LEVELS (PPM) <br /> K E ra>(3 Z'/ TPN DIESEL 10,000 '., 1000 I 100 <br /> FCOTNOTES: If documented soil and/or ground water contamination is presort, do not couple—re—the Leaching potential <br /> analysis. (i.e., site is cur virLy an UGT Contamination List for soil or greuld 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, scare 0 points. <br /> \3 Levels for 3TXSE are not applicable at a TPN =ncentratien of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECCPHIENDATION/CONCLUSION <br /> 1. Are 37X 3 E or TPM Concentrations , ALLLLoweble Levels I-Yes moI <br /> 2. Reccarnend Site Ctosur--I Test Nal X FIf Tet, Refer to Site Mitigation for Evalwtion <br /> VII. REVIEW EVALUATION - TO BE C01WLETED BY A SUPERVISOR/SENIOR <br /> CCNCUR WITH STAFF RECGNMENOATION FOR CLOSUREIYEsl ANO) REFERRED TO SITE .NITIGATIGN FCR EVALUATION(YES( INcI <br /> DATE REFERRED( / / (DATE CLCSURE LETTER .MAILED( <br /> NAME OF <br /> EVALUATCRI <br /> EH 23 30 (UGTWKSHT)\5/90 <br />