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SAN AVIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMEN WKEALTH DIVISION <br /> 1• UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> PAUSIZE <br /> CILITY SWEEPS CODE 25''1-1 <br /> / iJ � ..... TANK 10 it <br /> UEL TYPE <br /> II. GENERAL SITE HISTORY <br /> Is permit current? es o ermit - acility Status Code it GW Cant4umbees <br /> r of Tanks at facility ge of Tanks(if available) ype of Tank feel brgl ngl Dual <br /> Ili. TANK HISTORY <br /> Jas Tank tested? as o ailed precision test ? eso If yes, give dates) <br /> Jas a repair made to the tank system? yes No f yes, what was repaired? <br /> ry <br /> s repair done under inspection? es o ere soil samples analyzed? es oTXE Ppe of failure/discharge atestrophic Long-term leakage verfItl they: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> it Samples Received as 140 epth to Ground Water 3 of/Year I g3 ;$10 verage Annual Precipitation * 4 0-25 <br /> -Site WeLL(s) es o r J< Type Irr om <br /> S core S core S core <br /> istance to Yells) from Tank ft; ft; ft C 0 pts C 9 pts C pts <br /> 0 if 0 if 0 f <br /> R condition R condition R ondition <br /> . Site Feature - Leaching Potential Analysis 4iE is met E is wet E a met <br /> inimum Depth to groundwater from the Soil Sample (feet) _ _ >100 1-100 Q 25-50., <br /> ractures in subsurface (applies to foothills or mountain areas) None 9 Unknown PIresent <br /> verage Annual Precipitation (inches) KXXXXX <10 10-25 xxxxxxx 26-40_V <br /> -Made conduits which increase vertical migration p <br /> f leachate (i.e., septic systems, water wells, ponds) None 7 Unknown resent• <br /> ique site features: Recharge area, coarse soil, nearby wells. 9 At Least 4ore than <br /> Kxxxxx None one //�� one <br /> 1M8l <br /> COLlTOTALS>>>TOTAL POINTS + 36 + V 3Co <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS9 pts or more 41 - 48 pts 40 pts or less <br /> B T X E B T IX E <br /> on <br /> MAXIMl81 ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NAS <br /> Sample Result: INE 1000 100 10 <br /> IMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPM IESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil 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 grovel water.) <br /> ?I <br /> t dnptk is ;,PS ft+ 4nd s;�i ft,. ecAm 4�l„P,"- W,"5 # � fha use`abler► <br /> If precipitation is > 40 inches, score 0 points. <br /> \3_ Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX i E or TPH Concentrations > Allowable Levels Yes o ,• <br /> 2. Recommend Site Closure es If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> WITH STAFF RECOMMENDATION FOR CLOSUREES EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED ATE CLOSURE LETTER MAILED <br /> OF <br /> VALUATOR <br /> EN 23 80 (UGTWKSHTA5/90 <br />