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SAIL JOADUIIi COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HH DIVISION / <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> AME OF FACILITY C;,1f Of)�t,& EEPS CODE Z3 <br /> DRESS 6-5-6 f{o�pOLi $'�vr-J�7�.q ANK ID #T-5q non — O i <br /> TANK SIZE �yD Ga UEL TYPE Dr�G <br /> II. GENERAL SITE HISTORY ++ f <br /> is permit current? es o ermit # - acility Status Code Cf'6 oc.SoiL/GW Cont es o <br /> ember of Tanks at facility O ge of Tanks(if available) ype of Tank tees Fbrg{ ngl Dual <br /> III. TANK HISTORY , <br /> Jas Tank tested? es ' o ailed precision test ? es o 1f yes, give dates) <br /> as a repair made to the tank system? es No 11f yes, what was repaired? <br /> as repair done under inspection? es 40 Jere soil samples analyzed? es o I PH-G H-D b/EDB <br /> ype of failure/discharge atastrophic Long-term leakage verfill I Jjfk <br /> nown then: <br /> i <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> ail Samples Receivedes al1 epth to Ground Water qo� of/Year $6 : 63 verage Annual Precipitatio7core <br /> .25 <br /> -Site Wells) es o umber & Type Irr an ub S core 5 core S istanceto Well(s) frau Tank ft; ft; ft C 0 pts C pts C <br /> E 0 if 0 if 0 f <br /> R condition Rondition R ondition <br /> . Site Feature - Leaching Potential Analysis E is met E is met E s met <br /> inimum Depth to groundwater from the Soil Sample (feet) >300 1-1Q0 25-501 <br /> ractures in subsurface (applies to foothills or mountain areas) /0 None Unknown resent <br /> verage Arcual Precipitation (inches) xxxx <30 9 30-25 xxxxxx 25-402 <br /> i <br /> an-Made conduits which increase vertical migration None Unknown resent <br /> f leachate (i.e., septic systems. water wells, ponds) <br /> ore than <br /> nique site features" At least: Recharge area, coarse soil, nearby wells. xxxx Noneone one <br /> a i <br /> (( I <br /> COLUMN TOTALS>>>TOTAL POINTS 2.0 + <br /> ample Result: (B T X OR 0 RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or Less <br /> E T/veme-=n•oa S 7 f-rxze""D <br /> (+�-"rx-„G: p•A040 B T X E 8 S X E i <br /> �yleNas= o•zi MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 <br /> 50 50 .3 .3 1. 1. NAL . <br /> ample Result: <br /> SOLINE tODO 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) 100 � <br /> TPH- IESEL 1D,D00 1000 <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 List for soil or ground water.) <br /> a1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth <-5 ft., do not use table. <br /> L if precipitation is > 40 inches, score 0 points. <br /> L Levels for BTXBE are not applicable at a TPN concentration of 1Q ppm (gasoline) or 300 ppm (diesel). <br /> i <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> s <br /> 5 <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o j <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> Vit. REVIEW EVALUATICN - TO BE COMPLETED BY A SUPERVISOR/5 NIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE E5 O EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / �C// / y ATE CLOSURE LETTER HAILED I / <br /> AME OF - <br /> -VALUATOR <br /> EH 23 80 {UGTWKSH /90 <br /> * <br />