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r <br /> SAN d0A0UIN�_ ,/'Y PUBLIC HEALTH SEWICES/EN11IRONMTAL H JIVISION <br /> I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE fj <br /> NAME OF FACILITY SWEEPS CODE <br /> ADDRESS Op S G �1�.� TANK ID #1341-7 <br /> TANK SIZE ?, p FUEL TYPE wlD <br /> II_ GENERAL SITE HISTORY <br /> IS permit current? Yes No Permit # - Facility Status Code Doc.Soil/GU Cont Yes Na <br /> Number of Tanks at facility r Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test ? Yes No If yes, give date(s) <br /> Was a repair made to the tank system? Yes i No If yes, what was repaired? <br /> Was repair done under inspection? Yes No Were soil samples anal ed? Yes No STXE TPH-G TPH-01 Pb/EDB <br /> Type of failure/discharge catastrophic long-term leakage overfill L <br /> unknown Fother: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Ground Water ,7Ref/Year Average Annual Precipitation A= 14 10-6 <br /> On-Site Wells) Yes No Number & Type irr Dom Pub <br /> S Beare S Score S Scare <br /> Distance to Welt(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R condition R condition R condition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet) >100 51-100 75-50\1 <br /> Fractures in subsurface (applies to foothilts or mountain areas) None Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration 41 <br /> of leachate (i.e., septic systems, water welts, ponds) None Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby welts. At least More than <br /> xxxxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more - s 40 pts or Less <br /> g �•a:-nP5/-IPE—.�11�olP") <br /> a7_1 pp" B T xE 8 T x E <br /> x 4-1+rj MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) i 50 50 50 .3 .3 1- 1. NA\3 <br /> Sample esutt: rl�t GASOLINE 1000 100 10 <br /> A•jlaoPy "Ti�f"� MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> �. TPH-41 DIESEL 10,000 I 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 ground water.) <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth `5 ft., do not use table_ <br /> \Z If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTX&E are not applicable at a TPH concentration of 10 esel)• <br /> VI. STAFF RECOMMENDATION/CONCLUSION O V v7y ! <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes N <br /> 2. Recommend Site Ctosure Yes No *If Yes, Refer to Site Mitigation for Evaluation Tom= <br /> VII. REVIEW EVALUATION - TO 13E COMPLETED Y A SUPERVISOR/SENIOR 'T� � Z <br /> Ji wuU0 licei.'V6 <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES N0 REFERRED 70 SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAIL <br /> NAME OF <br /> EVALUATOR <br /> y—a! <br /> EH 23 80 CUGTWKSHT)\5/40 �) <br />