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SAN AN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENT HEALTH DIVISION <br /> 1. OF FACILITY UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> ATE /a-le, fid -9p <br /> AME <br /> � in - - WEEPS CODE <br /> DRESS <br /> /� �oZANK ID # 3 <br /> ANK SIZE a /Jc) <br /> UEL TYPE .y- 11 J 9 <br /> UeI ,l <br /> I1. GENERAL SITE HIST R <br /> Is permit current? es o �/ +» <br /> ermit p acility Status Code <br /> $-3 oc.Soi l/GW Cont as o <br /> weber of Tanks at facility O ge of Tanks(if available) ype of Tank teel Fbrgl Dual <br /> 111. TANK HISTORY <br /> as Tank tested? as o aited precision test 7 as <br /> o If yes, give date(s) <br /> as a repair made to the tank system? as No f yes, what was repaired? <br /> as repair done under inspection? as o ere soil samples analyzed? es o T%E PH•C PH-D b/EDB <br /> ype of failure/discharge atastrophic fang-term leakage verfill known they: <br /> IV. REMOVAL HISTORY (ATTACH INSPEC ION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Oil Samples Received as ✓ o epth to Ground Water &0' of/Year ( f <br /> ,�� verage Annual Precipitation <br /> -Site Well(S) as f o umber & Type Z Irr om ub <br /> istance to Well(s) from Tankb S core S core S core <br /> ,(,�(_ft; ft; ft C 0 pts C pts C pts <br /> 0 if 0 if 0 f <br /> Site Feature - Leaching Potential Analysis R ondit i on R ondltiOn R ondition <br /> E is met E is met Es nlet <br /> inimxm Depth to groundwater from the Soil Sample (feet) >100 <br /> 1-100 25-5OL <br /> ractures in subsurface (applies to foothills or mountain areas) None <br /> Unknown resent <br /> verage Annual Precipitation (inches) xxxx <10 q <br /> 10-25 xxxxxx 26-402 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None <br /> Unknown resent <br /> nique site features: Recharge area, coarse soil, nearby wells. <br /> At least S ore then <br /> xxxx None one one <br /> COLUMN TOTALS»>70TAL POINTS + * 7 r <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> ° I MAXIMUM ALLOWABLE B-T-X•E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NAL <br /> ample Result: ASOLINE 1000 100 <br /> A%IMUM ALLOWABLE TPM LEVELS (PPM) 10 <br /> TPH IESEL 10,000 1000 <br /> 100 <br /> OOTNOTES: ***If documented soil end/or ground water contamination is present, do not complete the teaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> 17 If depth is > 5 ft, and < 25 ft., score 0 points. If depth <=5 ft., do net use table. <br /> L If precipitation is > 40 inches, score 0 points. <br /> ,L3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure Fes I �/ If Yes, Refer to Site Mitigation for Evaluation <br /> V11. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITI CAT ION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> ARE OF <br /> VALUATORCm • V Ti <br /> EH 23 80 (UGTWKSHT)\5/90 <br />