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SAN 4AGUIN -Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE. n.1VISION <br /> I Q WORKSHEET FOR SITE CLOSURE EVALUATION OATS -Io —1,5— 7 <br /> (NAME OF FACILITY _u /� mus CDOE 3 1411 <br /> ADDRESS tel, IE: TANK ID # I,1h6 <br /> TANK SIZE /01 D 0 1 <br /> FUEL TYPE <br /> !S l <br /> II. GENERAL SITE HISTORY !` <br /> Is permit current? Yes No Permit # - Facility Status Code Doc.SOiL/GW Cant Yes No <br /> Number of Tanks at facility 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 Ho If yes, give date(s) <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? <br /> Was repair done under inspection? Yes No Were soil samples analyzed? Yes NB' TPH-G TPH-D Pb/EDB <br /> Type of failure/discharge catastrophic long-term leakage overfill unknown other: <br /> 1 <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 Ref/Year Average Annual Precipitation A= 14 10-25 <br /> On-Site Wells} Yes No Number & Type Irr Dom Pub <br /> 5 Score S Score S Score <br /> Distance to WeEL(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> D if 0 if O if <br /> R cdndition 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) �' 3.100 �51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills 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 i <br /> of leachate (i.e., septic systems, water we(ls, ponds) None Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby we(Ls. At Least More than <br /> xxxxxx one one one <br /> (4�' 0,)--. r <br /> COLUMN TOTALS>>>TOTAL POINTS <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts s or a <br /> x <br /> l o01c� r; o � B T X E B T X E <br /> F MAXIMUM ALLOWABLE a-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1 NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> 3 / lOX MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH DIESEL 10,000 1000 100 <br /> FOOTNOTES: 64 ***If documented soil and/or ground water contamination is present, do not complete the chin otentiaL <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> \1 If depth is > 5 ft. and c 25 ft., score 0 points. if depth <=5 ft., do not use table. <br /> \2 if precipitation is > 40 inches, score 0 points. I <br /> \3 Levels for BTX&E are not applicable at a TAH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> ,I <br /> 1. Are BTX & E or TPH Concentrations > Allowable LeveEs *Yes 1A I <br /> No <br /> 2. Recommend Site Closure Yes No If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION TES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED li <br /> NAME OF <br /> EVALUATOR N <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> i� <br /> .p <br /> t <br />