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� �i n- , I <br /> SAN d,ACU,, CCUNI./ �?HLIC HEALTH SERVICES/ENVIRCNMENTAL HEALT SiON ATE <br /> I� 1UGS RKSHEET FOR SITE C%*00LOSURE EVALUATION <br /> K <br /> iSWEEPS CODE <br /> AME OF FACILITY <br /> i �OD <br /> I TANK! ID 9 <br /> nDaE5s <br /> AXS12E <br /> D UEL TYPE <br /> if. GENERAL SITE HISTORY �I <br /> ility Status code �i oc.Soil/GW Cont e3 <br /> ac0 <br /> Is permit current? es 4 ermiL�iF r <br /> unber of Tanks at facility ge �Tnk,(V available) ypa of Tank feel hrgl no <br /> l Dual <br /> III. TANK HISTORY <br /> Jas Tank tested? es o ailed precision teIf yes, give date( <br /> ,O <br /> 2 'kes o s} <br /> } <br /> as a repair made to the tank system? is No f yes, chat was repaired? 4. <br /> 'as repair done under inspection? es o ere soil samples analyzed? es a T%E PN-G PH-D <br /> 1 <br /> ype of failure/discharge atastrophic long-term leakage verfi[l noun the <br /> TV. REMOVAL HISTORY (ATTACH INSPECTION REP{ORI FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANAL7SIS) <br /> �6 Tve,*ag,,' nnual Precipitation = 4 0-25 <br /> ail samples'Received es a epth to Ground Water of/Year - <br /> -Site Wel!(s) es o umber 3 '`ype Irr ! Asn ub S corcore S core <br /> {t; I ft C 0 ppts C 'pts <br /> istance to Welt(s) frau Tank ft. 0 if 0 if O f <br /> Rmditicn R condition R ordition'' <br /> 1. Site Feature - Leaching Potential Analysis E s met E is met E met <br /> s <br /> inimum Depth to groundwater from the So'it Sample {feet)= <br /> 51-100 <br /> ractures ink ubsurface (applies to foothills or mountain areas) <br /> Hone Unknown resent <br /> verage Annual Precipitation (inches) ;? xxx <10 4 10-25 xxxxxx 25-40\2 <br /> an-Rade corx4jits which increase vertical migration (� Unknown resent , <br /> f leachate (i.e., septic systems, water) wells, ponds) I! None i <br /> At teas[ 4ore than <br /> ique site features: Recharge area, coarse soil, nearby wells. (�1 <br /> E�, xxxX None "� one one <br /> COLUMN TOTALS»>TOTAL POINTS ! <br /> amp[q r ult: (B T X OR E} RANGE OF TOTAL POINTS 9 pts or more i41 - 48 pts 40 pts or lessr� <br /> -r.�I 4 Il B T X E 7.31� <br /> TMAXIMUiIALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 3 1. i, NA\3 <br /> 1 <br /> ample Result: 1 ASOL'IHE 1000 " 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> 1000 !'4n` ' 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 <br /> LI <br /> for;isail or ground water.) <br /> \1 If depth is > 5 ft. land < 25 ft., score 0 points. If depth <=5 ft., do not use table: <br /> \2 If precipitation is'l> 40 inches, score 0 points. <br /> 1� \3 Levels for BTXBE are rat applicable at a TPH concentration of 10 ppn (gasoline) or 100 ppm (diesel). I� <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are STX'lt E or TPH Concentrations > Allowable LeveYes e PC3 I*10 <br /> 2. Recommend Site Closure es o ;� � If Yes, Refer to Sive Mitigation for Evaluation i e o- <br /> L t7l 1 . <br /> VII. REVIEW EVALUATION • TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> k F <br /> ONCUR WITH STAFF RECCHMENDATION FOR CLOSURE ES O� EFERRED TO SITE MITIGATIOR FOR EVALUATION ES O <br /> ATE REFERRED / / " ATE CLOSURE LETTER MAILED 1 / <br /> JAIMEOF <br /> ;VAL { <br /> VALUATOR <br /> Ex 23 80 (UGTUKSHi)\5/90 ' <br /> 4 f3' <br />