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LTH <br /> SAN COUNTY PUBLIC <br /> WORKSHEETAFOR SITES CLOSURE EVALUATION DIVISION DATE <br /> 1. <br /> ' SWEEPS CODE <br /> NAME OF FACILITY i <br /> TANK ID <br /> ADDRESS <br /> TANK SIZE FUEL TYPE <br /> 11. GENERAL SITE HISTORY *** <br /> Is permit current? Yes No Permit # - Facility Status Code Doc.SoiL/GW Cont Yes No <br /> Age of Tanks(if available) Type of Tank Steel FbrgL Sngl Dual <br /> Number of Tanks at facility <br /> III. TANK HISTORY <br /> yes, give date(s) <br /> Was Tank tested? Yes No Failed precision test 7 Yes <br /> No If <br /> Was a repair made to the tank system? Yes No if yes, what was repaired? <br /> Was repair done under inspection? Yes No Were soil samples ana Lyzed? Yes No BTXE TPH-G TPH-D 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 /> to Grpund Water Ref/Year <br /> Average Annual Precipitation A= 14 10-25 <br /> Soil Samples Received Yes No Depth <br /> On-Site WeLI(s) Yes No Number 8 Type Irr Dom Pub S Score S Score S Score <br /> Distance to Wells) from Tank i i fc; ft; ft C 10 pts C pts C pis <br /> 0 if O f 0 f � <br /> R condition R condition R condition <br /> V. Site Feature - leaching Potential Analysis <br /> E is met E is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet) <br /> >100 51-100 ( 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) <br /> None L` Unknown Present <br /> xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> Average Annual Precipitation (inches) tq <br /> Man-Made conduits which increase vertical migration None Unknown Present <br /> of leachate (i.e., septic systems, water wells, ponds) <br /> At least More than <br /> Unique site features: Recharge area, coarse soil, nearby wells. xxxxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS <br /> Sample Result: IS T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or Less <br /> B T % 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 /> GASOLINE 1000 100 10 <br /> Sample Result: <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) 100 <br /> DIESEL 10,000 1000 <br /> TPH <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 <br /> nsoil <br /> ot ortground water.) <br /> \1 if depth is > 5 ft. and < 25 ft., score 0 points. if depth <br /> \2 If precipitation is > 40 inches, score 0 points. tion of 10 ppm (gasoline) or 100 ppm (diesel). <br /> \3 Levels for BTXBE are not applicable at a TPH concentra <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels *Yes No <br /> 2. Recommend Site Closure Yes No *If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SuPERVLSOR/SENIOR <br /> CONCUR WITX STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />