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SAN 1CAOUIN C."TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION !DATE <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> [ SWEEPS CODE! j <br /> !NAME IF FACILITY ; <br /> !TANK ID #} <br /> IADDRESSI <br /> TANK SIZE (FUEL TYPE! I <br /> [I. ]ENERAL SITE 4ISTCRY !I i <br /> [s permit current?IYesl INoi iPernit <br /> �l Facility Status Codel IDoc.SaiL/GW ContlYesl ;Nal <br /> i iT of TanKlSteetl (Fbrgl ISngl Dual! <br /> iNTxnper of Tanks 3c facility! -Age of Tanks(if 3vailaole)I !Type <br /> II!. -ANK 4ISTCRY <br /> ?i INoI l[f Yes, give Cate(s)l <br /> Was Tank rested?jYesl IHoi jFaiLed ?recision test Yesj <br /> I' ' <br /> yes, what was repaired?l <br /> Was a repair ,made to ,he tank System es <br /> Noj itf 1 <br /> Was -eflair Cone under insoectian?!Yesi iNoi ;Were soil samples 3nalyzed?;Yesl iNoi IBTXEI ;TPH-GI IiPH-OI jPb/EDB! <br /> I <br /> 'voe if failure/discnargei IcaLaStr:pnic. !long-term leakage :over=!!!! !unknown) :other. <br /> j <br /> iv. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR 3ITE DETAILS/COLLECT DATA ;OR LEACHING POTENTIAL ANALYSIS) <br /> ;oil iamotes ReceivedlYesl lNol IOeoth to around `dater! fRef/Year! !Average Anrx+at PrecipicationlA=it4 i10-Z51 <br /> On-Site Wel!(s)IYesi No! N�snber 3 Type! Iirrl LDISScore I S !ScoreScore <br /> r is C i9 pLs C ;5 pts <br /> :t; ft; i10 p l <br /> 0:5t3nce :o Wetl(s) from Tank 0 lif O cif 0 �' <br /> Z !condition: 2 !conditionI R !condn <br /> 'is Wt .met is net <br /> v. Site Feature Leaching Potential Analysis <br /> l = is I _ ! <br /> 1 I >IGO ;51-100 j j 5-50\1 i <br /> 41nimun Deptn :o groundwater gram tae Soil Sample (feet) 1 <br /> i '1nKnown j !Present <br /> F,3c,ures in subsur=ace (aPpties :o 'oothills or maintain areas) ! Name ; <br /> xxxxxxi <10 !xxxxxxxi <br /> ,iversge AnnuaL Precipitation Cines) 1 <br /> 9 'O-ZS <br /> nc <br /> Man-^rade conduits wnica increase vert,caL migration 14one 1 Unknown IPresent <br /> -3raacnate (i.e., septic systeas, water wells, ponds) i 1 <br /> i i I At least! More than <br /> Unicue site -eatures: Recharge area, coarse soil, nearoy wells. �xxxxxxi Pane I ane! I one <br /> COLUMN TOTALS»>TCTAL POINTS ! <br /> RANGE OF TOTAL ?OINTS 49 pts or more :1 -d Pts 44 Pts or less j <br /> Sample Result: (8 T X OR E) ; <br /> i T X <br /> NA\3 <br /> T X I E 3 c <br /> MAXIMUM ALLOWABLE 3-T-X-E LEVELS (PPM) <br /> 1 3� :0, 50 i0 E .3 .3 ! t.l t. <br /> :GASOLINE 1000 100 I 10 ! <br /> Sampte Result: <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) 10,300 I 1000 I 100 <br /> TPH ID(ESEL <br /> and/or FOOTNOTES: <br /> ^"�tf documented soil aor ground s curwater contamination is oresent, do not complete the leaching potential 1 <br /> analysis. L and/ site is on UGT Contamination Lis: far soil or ground water. <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levets for 3TX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diene!). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> j Are 3TX 3 E or TPH Concentrations > Allowable Levels I*Yes1 I2. NoI 1 <br /> Recommend Site ClosurelYesf IND) If Yes, Refer to Site Mitigation for cvaivation <br /> '11:. .REVIEW EVALUATION TO 3E COMPLETED 3Y A SUPERVISOR/SENIOR <br /> !CONCUR WITH STAFF RECCMMENOATION FOR CLOSUREIYESI INOI !REFERRED TO SITE MITIGATION FOR 'cVALUATIONIYES) 1401 <br /> ! <br /> !DATE REFSRREDI DATE CLOSURE LETTER MAILED! <br /> NAME OF <br /> ;EVALUATCRI <br /> EH 23 30 IUG,'UKSHT)\5/90 <br />