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SAN ASO COtN1TY PUBLIC HEALTH SERVICES/E <br /> NVIRONMENTAL HEALTH DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> kW QF FACILITY EPS CODE <br /> 7 ANK 1D #FAINKZE IFUEL TYPE <br /> It. GENERAL SITE HISTORY <br /> +r* <br /> s permit currant? as o ermit R 3 - scitity Status Code oc.Soil/GW Cant es <br /> r of Tactics at facility ge of Tanks(if available) ype of Tarn teet I vfbr9i t punt <br /> 111. TANK HISTORY <br /> s Tank tested? ea o ailed precision test ? es o If yes, give date(s) <br /> s a repair made to the tank system? yes No 11f yes, what was repaired? <br /> repair done under inspection? es o ere Boit samples analyzed? as o TXE PH-G PH-0 EDB <br /> ype of failure/discharge atastrophic tong-term leakage verfitl ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soft Samples Received as o epth to Ground Water 3 0 of/Year 06 ; P verage Annual Precipitation - 4 0-25 <br /> -Site WaII(a) ea o r i Type Irr am <br /> istance to Wells) from Tactic ft; ft; ft C 10 ScopC core S ore <br /> Pts pts C pts <br /> 0 if 0 if 0 f <br /> i. R ondition R rondition R ondition <br /> Site Feature - Leaching Potential Analysis E is met E is met E s met <br /> inimum Depth to groundwater from the Soft Sasple (feet) &'' >100 1-100 0 25-50.0 <br /> ractures in subsurface (applies to foothills or mountain areas) la None unknown resent <br /> verage Annual Precipitation (inches) xxxx <10 9 10-25 xxx 26-4012 <br /> n-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) �0 None Unknown resent- <br /> ique site features: Recharge area, coarse soil, nearby wells. At least fore than <br /> KXXXXX None one one <br /> COLUMN TOTALS»>TOTAL POINTS 2D , g + 38 <br /> I* Result: (8 T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> ,3 <br /> 6T X E 8 T I X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NAa <br /> ample Result: r:E <br /> NE 1000 100 10 <br /> 4AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> PH 1 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/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 grand water.) <br /> L If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> L If precipitation is > 40 inches, score 0 points. <br /> ,L3 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECWHENDATION/CONCLUSION <br /> 1. Are BTX.& E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Reconsend Site Closure es If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> PVALUWITH STAFF RECOMMENDATION FOR CLOSURE ES EFERRED TO SITE MITIGATION FOR EVALUATION ES <br /> AIOR <br /> EFERRED / / ATE CLOSURE LETTER MAILED <br /> F <br /> EN 23 80 (UGTWKSHT)%5/90 <br />