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1k* .✓ <br /> SAH JOAOUIN i.LrY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEtf DIVISION <br /> I. UGST WCRKSHEET FOR SITE CLOSURE EVALUATION � ATE <br /> AME OF FACILITY � w J V (IJ� EPS COOS <br /> ORE55 ?/b �L� AHK IO # <br /> IANX SIZE UEL TYPE �� <br /> 11. GENERAL SITE HISTORY <br /> is permit current7 es o ermit # - acitity Status Code oe.Soit/GW Conc es o <br /> umber of Tanks at facility ge of Tanks(if available) IType of Tank teel brgl ngL Dust <br /> til. TANK HISTORY <br /> Jas Tank tested? es a ailed precision test 1 es o If yes, give date(s) <br /> as a repair made to the tank system? IYes No I 11f yes, what was repaired? <br /> ns repair done under inspection? es Fa 14ere soil samples analyzed7 es I o I TXE I PH-G I PH-fl b/EDS <br /> ype of failure/discharge atastrophic long-term leakage verfi[t own cher: <br /> )V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE OETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es a epth to Ground VaterfA of/Year tlS 6 D verage Amuai Precipitation i= 4 0-25 <br /> -Site Wells) es a umber 3 Type irr cm b <br /> S core S core S core <br /> (stance to Wells) from Tank ft; ft; ft C 0 pts C 9 pts C pts <br /> 0 f 0 if 0 f <br /> R ondition R condition R ondition <br /> Site Feature - Leaching Potential Analysis E s met E is met E s met <br /> inimum Depth to groundwater from the Solt Sample (feet) D ,100 1-100 25-50\I <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown 31resent <br /> %verage Amual Precipitation (inches) xxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water welts, ponds) None Unknown resent <br /> ique site features: Recharge area, coarse soil, nearby wetLs. At least are than <br /> xxxx None - I one one <br /> COLUMN TOTALS—TOTAL POINTS Iv * 3G * �6 <br /> Sample Result: Ca T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> �r.jG p11�•� �r3�/)�► B T X E B T X E <br /> = dR�[ppkf NAXIHLMM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> ample Result: ASOLINE 1000 100 10 <br /> IMLJM ALLOWABLE TPH LEVELS (PPM) <br /> �] n TPH•-oft, IESEL 10,000 1000 100 <br /> COTNOTES: '"If documented soit and/or ground water contamination Is present, do not complete the Leaching potential <br /> analysis. (i.e., site is currently on UCT Contamination List for soit or ground water.) <br /> \1 If depth is > 5 ft. and < 25 ft., scare 0 points. If depth -5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levets for BTXU are not applicable at a TPN concentration of 10 ppm (gasotine) or 100 ppm (diesel). <br /> It. STAFF RECOMMENDATION/CONCLUSION P/(L J TI O <br /> I. Are BTX 1, E or TAH Concentrations > At towable Levels Yes o {�jrii�- yj <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation L 1 <br /> ill. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CNCJR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE HITIGATICH FOR EVALUATION ES <br /> ATE REFERRED / / ATE CLOSURE LETTER HAILED f / <br /> LAME OF <br /> :vALUATOR <br /> EH 23 90 (UGTWKSHT)\5/90 <br />