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SAN XACUIN CCUNTY IC HEALTH SERVICES/EHVIRCNmEHTAL HEALTH 0 ON <br /> UGST w,.nXSHEET FOR SITE CLOSURE EVALUATICN DATE V Z <br /> F <br /> ;'E 0f FAC;L[iT I I a D �e��� �AW .+EEPS CCCE <br /> vL C• TANK 10 1 <br /> �00RESS / �+' f <br /> TANK SIZE l(� �U UEL TYPE I leo <br /> 1. GENERAL SITE HISTORY <br /> Is permit current? les o ermit 4 racility Status Cade I �oe.Sai /GV Cant es o <br /> unCer of Tanks at facility ge of Tanks(if available) ! Ij ype of Tank tee) FbrgL ng <br /> Oual <br /> It. TANK HISTCRT <br /> I <br /> Tank tested? Ies o ailed precision test es o If yes, givedates) <br /> �as a repair made to the tank system? 1Yes No 1 vilf yes, what was repaired? <br /> 'as repair done under inspection? Ies I q0 Mere soil samples analyzed7 es o 1, <br /> TXE PH-G IPH-0 b/ED8 <br /> Type of failure/discharge atastrophic hong-term leakage verfill I nknown cher: <br /> V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FCR LEACHING POTENTIAL ANALYS(S) <br /> oil Samples Received es o epth to Ground Water of/Year verage Annual Precipitation = I14 0-25 <br /> Site Wells) es o umber b Type irr cm vb I <br /> S Score S Score S 3core <br /> istance to Well(s) from Tank ft; ft; ft C 10 pts C 9 Pts C 5 Pts <br /> 0 if 0 if 0 if <br /> R onditicn R ccndition R zordicion <br /> 1. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> .iinimun Depth to groundwater from the Soil Sample (feet) I >100 I 1 100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None I Unknown 7 <br /> present <br /> verage Arcual Precipitation (inches) xxxx <10 9 10-25 xxxxxx 26-40\2 <br /> an-made corduits which increase vertical migration <br /> f Leachate (i.e., septic systems, water wells, ponds) None I Unknown I resent <br /> l'nique site features: Recharge area, coarse soil, nearby wells. At least ) Mare than <br /> x_xxxxx More one one <br /> � COLUMN TOTALS <br /> »>TOTAL POINTS <br /> IzMcLe Result: (3 T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 Pts or less <br /> I <br /> MI <br /> T X E 3 T X EMAXIXLH ALLCt1ASLE 3-T-X-E LEVELS (PPM) 50 750 50 .3 .3 1. 1. NA <br /> ;aapte Result: SASCLINE 1000 100 10 <br /> AXIHUM ALLCGAaLE TPH LEVELS (PPM) <br /> TPH IESEL 10,000 1100 100 <br /> rCOTHOTES: ***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 ground water.) <br /> \1 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 /> \3 Levels for 3TX3E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> 1. STAFF RECOIVEVOATION/CONCLUSION <br /> 1. Are 3TX 3. E or TP4 Concentrations > Allowable Levels Yes o <br /> ! 2. Recc4Tnend Site Closure es o I If Yes, Refer to Site Mitigation for Evaluation <br /> II. REVIEW EVALUATICN - TO BE CCYPLETED BY A SUPERVI SCR/SENICR <br /> _CNCJR WITH STAFF RECCHHENDATICN FCR CLOSURE SEs 0 EFERRED TO SITE mITICATICN FCR EVALUATICH IIYESI 0 <br /> ATE REFERRED / �� / CI Z_ ATE CLOSURE LETTER HAILED <br /> WIE CF <br /> ;V,ILUATCR <br /> EH :3 80 (UGTuKS' T)\5/9 <br />