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14 SAN d0A4U. _Olt'�Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL AL1 [VISION <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE 2 <br /> J <br /> !NAME OF FACILITY $5 LD(_L S L SWEEPS CODE <br /> [ADDRESS TANK ID # <br /> 'TANK SIZE ` FUEL TYPE <br /> :L. GENERAL SITEuvlz <br /> HIST RY <br /> *** <br /> Is permit current? Yes x No Permit it - Facility Status Code �1� Doc.Soil/GW Cont Yes No <br /> ;Number of Tanks at facility 3 Age of Tanks(if available) ML�. Type of Tank steel FbrgL Sngl Dual <br /> III. TANK HISTORY +� <br /> .Was Tank tested? Yes No Failed precision test ? Yes No If yes, give date s) <br /> i <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? <br /> 'was repaiEdone under inspegStion? Yes No Were soil samples analyzed? Yes No BTX;Type of fdischarge catastrophic tong-term Leakage overfillunknawn other: <br /> IV, REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Sail Samples Received Yes No Depth to Ground Water IId Ref/Year OHO ; S 3 Average Annual Precipitation A= 14 10 25 <br /> �On-Site WeLI(s) Yes No Number & Type Irr Dom Publ S Score S Score S Score <br /> :Distance to Welts) from Tank ft; ft; #t C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if a if <br /> R condition R condition R condition <br /> IV. Site Feature - Leaching Potentiat Analysis E is met E is met E is met <br /> :Minimum Depth to groundwater from the Soil Sample (feet) >100 51-100 25-50\1 <br /> [Fractures in subsurface (applies to foothills or mountain areas) ID None Unknown Present <br /> I <br /> ;Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> 'Man-Made conduits which increase vertical migration None Unknown I Present <br /> of Leachate (i.e., septic systems, water wells, ponds) <br /> 7--q- <br /> iUnique site features: Recharge area, coarse, soil, nearby wells. At least More <br /> xxxxxx None one one <br /> Io <br /> a + o _ -7 <br /> COLUMN TOTALS»>TOTAL POINTS <br /> !Sample TZ <br /> (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> NU X--A Q APYY? B T X E 3 X E% MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 J.T <br /> 3 1. 1- NA\3 <br /> :Sampte Result: <br /> GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) 1000 100 <br /> TPH( DIESEL 10,000 <br /> IFOOTN xY T� ***If documented soil and/or ground water contamination is present, da net complete the leaching <br /> L� analysis. (i.e., site is currently an UGT Contamination List for soil or ground water.) <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points, If depth r-5 ft., do not use table. <br /> 1111 \2 If precipitation is > 40 inches, score 0 points. r <br /> \3 Levels for STX&E are not appticable at a TAH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes xj No <br /> I <br /> 2. Recommend Site Closure Yes No If Yes, Refer to Site Mitigation for Evaluation <br /> V;!. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO I REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / DATE CL S RE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> ;5H 23 80 (UGTWKSHT)\5/90 <br />