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5AN JOAOUTANTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL oil DIVISION GATE � � <br /> UGIT WORKSHEET FOR SITE CL05URE EVALUATION <br /> 1SWEEPS CODE( a 3 <br /> NAME OF FACILITY �" <br /> ABOR999 7 O S-I"OG TANK ID 411I3,1 - IU 5—1`a4th—�I/^y� <br /> TANK SIZE 000 FUEL TYPE L r-> old WCC � mre- . I J / 7 ; <br /> It. GENERAL SITE HISTORY <br /> Permit C ' <br /> facility Status Cade Doc-Soil/GW Coni Yes Me <br /> Is permit current? Yes Na <br /> ABe o4 Tanks(i4 available) Type of Tank Steel Fhrgl Sngl Oual <br /> Number of Tanks at facility Q <br /> 111. TANK HISTORY r r 7^ 8g <br /> Was Tank tested? Yes No failed precision test Yes <br /> No [f yes, give date(s) <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? <br /> Was repair done under inspection?(Yes INo Were soil samples analyzed? Yes Nol BTXEI (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 /> Soil Samples Received Yes No Depth to Ground Water 50 Ref/Year <br /> S Average Annual Precipitation)A= 14 10-25 <br /> on-Site Wells) Yes No Number & Type Irr Dom) Pub S Score S Score S Score <br /> Distance to Wells) from Tank ft; ft; it C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R condition R condition R condition <br /> V. Site Feature - Leaching Potential Analysis <br /> E is met = is met E is met <br /> 50,11 <br /> Minimum Depth to groundwater from the Soil Sample (feet) <br /> 36' 1573 >1ao I I51-100 -5 I zs-Minimum <br /> Fractures in subsurface (applies to foothills or mountain areas) <br /> ' I None I I Unknown Present <br /> Average Annual Precipitation (inches) <br /> xxxaxx <10 9 110-25 xxxx=1 26-40\2 <br /> Man-Made conduits which increase vertical migration I own None 1 1 UnknPresent <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 we one <br /> COLUMN TOTALS»>TOTAL POINTS <br /> ro 1 1A1 5 11. 9j,a <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 4a pts 40 pts or less <br /> A/b B T X E8 T X E <br /> MAXIMA ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 501 50 .3 .3 11. 1. NI <br /> `` GASOLINE 1000 100 10 <br /> S ,leK e_ssu�t�14 A � MAXIMLAI ALLOWABLE TPH LEVELS (PPM) <br /> ry) DIESEL 10,000 1000 100 <br /> TPH <br /> FOOTNOTES: <br /> —•If documented soil and/or ground water contamination is present, o not cortplete the eaching potential <br /> analysis. (i.e., site is currently an UGT Contamination Li t for sail or and water. <br /> \1 If depth is > 5 it. and < 25 ft., scare 0 points. If depth <5 ft., use table. <br /> \2 If precipitation is > 40 inches, scare 0 points. <br /> \3 levels for STX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> m?P1� <br /> tootC G <br /> VI. STAFF RECOMMENDATION/CONCLUSION p <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels 'Yes Rol <br /> x <br /> >, Recommend Site Closure Yes No •If Yes, Refer to Site Mitigation for 'cva Luaiian I Q.S-S&S L <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A sUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSUREIYES- IND IREFERRED TO SITE MITIGATION FOR EVALUATION(YES IND <br /> DATE REFERRED / / <br /> GATE CLOSURE LETTER MAILED <br /> NAME OF C N — <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />