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I ow- ✓ _ C r f .4 <br /> SAI! JOAOUI�uNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL INW V.-DIVISIOFI AT <br /> I� UGST WORKSHEET FOR SITE CLOSURE EVALUATION �� �G Q <br /> AME OF FACILITY --rr EPS CODE <br /> DRESS j(p �. t)(5- <br /> ANx ID a#. <br /> TANK Si2E UEL TYPECr.cl-)qS <br /> 'R <br /> 11. GENERAL SITE HISTORY i <br /> ww <br /> 1s permit current? es o ermit tl - acility Status Code oc-So il/GW Cont es o <br /> umber of Tanks at facility ge of Tank (if available) �-I^ ype 1 ii <br /> ;of Tank Leel FbrgL ngl Dual <br /> .s <br /> III. TANK HISTORY <br /> Jas Tank tested? as o ailed precision test T eso 1f ;yes, give date s) <br /> as a repair made to the tank system? Yes No f yes, what was repaired? I 're yi-f <br /> Jas repair done under inspection? as a ere soil samples analyzed? es F o TXE PH-G PH-D b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfil( Hawn they: <br /> IV. REMOVAL HISTORY (ATTACH INS CTIOH REPORT FOR SITE DETAILS/COLLECT DATA FOR, LEACHING POTENTIAL ANALYSIS) <br /> ail Samples Received es epth to Ground Water 20� of/Tear ;Sb verage Annual Precipitation 4 0-25 <br /> -Site Well ea o umber It Type Irr om S coreQ S core S core <br /> istance to WeLI(s) from Tank ft; ft; ft C BBB 0 pts C 9 pts C i pts <br /> 0 if O if O f <br /> Rondition R condition R ondition <br /> Site Feature - Leaching Potential Analysis E is meir E is met E s met <br /> inimum Depth to groundwater from the Soil Sample (feet)?j�,. 5��, >100!� 1-100 25-50\ <br /> ractures in subsurface (applies to foothills or mountain areas) Nonell q Unknown resent <br /> %verage Annual Precipitation (inches) xxxxxx ,10 !N 9 10-25 pumxxxx 26-40,\2 <br /> an-made conduits which increase vertical migration <br /> f leachate Ei.e., septic systems, water wells, ponds) None; Unknown resent <br /> pique site features: Recharge area, coarse"sail; nearby wells. N At least 4ore than <br /> xxxx None, one one <br /> i! <br /> COLUMN TOTALS»>TOTAL POINTS +I! 3� ✓ T" f <br /> ample Result: (B T X OR E) RANGE OF TOTAL POI4TS9 pts or more 41 - 48 pts 40 pts or less <br /> $Y_0-+5Ff� x= Zo" <br /> Y 2 S M B T'{ X E B T XJE <br /> �- MAXIMUM ALLOWABLE B-T-X-E LEY£L5 (PPM) 1 5fl 5D SO .3 J.3 1. 1. NAL3 <br /> Sample Result: ASOLINE IDOO E 100 10 <br /> 1MUM ALLOWABLE TPH LEVELS (PPM) <br /> O D TPH IESEL 10,000 it 1000 100 <br /> FOOTNOTES, ***If documented sail 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 soil or ground water.) 1 <br /> L If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> L <br /> if precipitation is > 40 inches, score 0 points. # j <br /> L Levels for BTX8E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> r <br /> 1. Are 137X & £ or TPH Concentrations > All ble Levels Yes a is <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE E5 0 EFERRED TO SITE MITIGATION FOR EVALUATION fES 0 <br /> ATE REFERRED ATE CLOSURE LETTER MAILED <br /> AME OF -� <br /> vALua70R ��y ;� 1 <br /> EH 23 80 (UGTWKSHT)\5/90 # i <br /> �I �1 <br />