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I� SAN AIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTA HEALTH DIVISION <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> Of FACILITY u <br /> rAWK <br /> SS C� EPS CODE <br /> I <br /> AN <br /> K ID - <br /> SIZE UEL TYPE <br /> II. GENERAL SITE HISTORY <br /> Is permit current? es o ermit * - lFaciLity Status Code oc-Sbit/GW Cant e«sksobe . <br /> r of Tanks at facility ge of Tanks(if availebte) ype of Tank feel brgl l poet <br /> III. TANK HISTORY <br /> Jas Tarn test <br /> ed? es o ailed precision test ? as 0 if as <br /> Y , give date(s) / <br /> Jas a repair arode to the tank system? es No f yes, what was repaired? <br /> Jas repair done under inspection? es o ere soft samples analyzed? ec o TXE PH-G PH-D EDB <br /> hr–of failure/discharge atestrophic tong-term leakage verfitl they: <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 Wate of/Year ; 86 verage Annual Precipitation 4 0- <br /> 3n-Site Walls) es o umber & Type Irr om <br /> istance to Wells) frau Tank —ft; S care S core S core <br /> ft; ft C 0 pts C pts Cp is <br /> 0 f 0 if 0 f <br /> i. Site Feature - Leaching Potential Analysis R andition R ondition R ondition <br /> E s met E is met E s met <br /> inion Depth to groundwater from the Soil Sample (feet)2&z! = 7 >100 1-100 25-50.0 <br /> ractures in subsurface (applies to foothills or mountain areas) <br /> /D Nom' Unknown resent <br /> verage Annual Precipitation (inches) xxxx c10 9 10-25 xxxxxxx 26-40L <br /> n-Made conduits which increase vertical migration <br /> f Leachate (i.e., septic systema, water wells, ponds) ,/p None Unknown [resent, <br /> ique site features: Recharge area, coarse soft, nearby welts. At least re than <br /> Kxxxxx None 9 one 0/1e <br /> COLUMN TOTALS»>TOTAL POINTS 20 / + 38 <br /> ample Result: (B T X OR E) RANGE Of TOTAL POINTS F9 pts or more 41 48 pts 40 pts or Less <br /> 6 7.6 0 2-1 - — JX E <br /> Z 1, MAXIMUM ALLOWABLE B-T•X-E LEVELS (PPM) 1 150 <br /> 50 50 .3 -3 1. 1.SampNAS <br /> le Result: SOLINE 1000 100 10 <br /> IMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH 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 soft or ground water.) <br /> L 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 /> _U 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 & E or TPH Concentrations > Allowable Levels Yes o 'I <br /> 2• Recommend Site Closurees o I If Yes, Refer to Site Mitigation for Evaluation <br /> VI1. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> WITH STAFF RECOMMENDATION FOR CLOSURE ES EFERREO TO SITE MITIGATION FOR EVALUATION ES 0 <br /> 1 I <br /> r <br /> EfERRED / ATE CLOSURE LETTER MAILEDFTOR <br /> EH 23 80 (UGTWKSHT)\5190 <br />