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SAN ICA* _VTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL• )( DIVLSION ATE •'-� -, -i) `l <br /> 1 UST WORKSHEET FOR SITE CLOSURE EVALUATION _ <br /> ECORD ID <br /> J AME OF FACILITY EeLl C -./- / c' <br /> DDRESS �i..,t ANK IO # -_f k&7 — � `i <br /> ANK SIZE �i C,�;�.,�i' UEL TYPE ��q��� <br /> II. GENERAL SITE HISTORY <br /> Its permit current? es o k ermit # - aciliry Status Cade oc.Soil/GU Cant es o <br /> f e of Tank(if available) '� ype of Tank /teel Fbrgl ngl Dual <br /> umber of Tanks at facility Z; 9 +� <br /> III. TANK HISTORY <br /> was Tank tested? es o ailed precision test v es o If yes, give date(s) <br /> -as a repair made to the tank system? as No f yes, chat was repaired? <br /> Mas repair done under inspection? as o ere soil samples analyzed7 es o <br /> TXE PH-G PH-D 6/EDB <br /> hype of failure/discharge atastraphic Long-term Leakage verfill known I they: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es o epth to Ground Nater 5J of/Year <br /> verage Annual Precipitation k= 4 0-25 <br /> n-Site WeLL(S) es a umber & Type Irr am uh <br /> S core S Score <br /> istance to Wells) from Tank ft; ft; ft C 0 pts OC Ifp[s CO if 0 f <br /> R ondition R condition <br /> l/. Site Feature - Leaching Potential Analysis E s met E is met E is met <br /> >100 1-100 t, 25-5011 <br /> iNinimum Depth to groundwater from the Soil Sample (feet)j0- _ 3` <br /> �F ractures in subsurface (applies to foothills or mountain areas) <br /> None Unknown resent <br /> <10 9 10-25 xxxx 26-4012 <br /> 'overage Annual Precipitation (inches) xxxx <br /> ;Ian-Made conduits which increase vertical migration None Unknown resent <br /> sof leachate (i.e., septic systems, water welts, ponds) <br /> At least ore than <br /> llnique site features: Recharge area, coarse soil, or welts- ane one <br /> j (Muncipal=>2000 ft; domestic=>500 ft; irr/agricultural=present) /JX=x None <br /> COLUMN TOTALS»,TOTAL POINTS <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 47 - 48 pts 40 pts or Less <br /> IB=,(�Q cB= ND g T X E B T X E <br /> -r= .O d u X� -a;,>- MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NAL <br /> lP14 D_ SOLINE 1000 100 10 <br /> ,Sample Result: -.�� <br /> TPN G j I' ' TPH fESEL 10,000 <br /> RXIMUM ALLOWABLE TPH LEVELS (PPM) 100 <br /> 1000 <br /> OOTNOTES: ..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 4=5 ft-, do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. . gasoline) or 100 (diesel). <br /> \3 Levels for BTX&E are not applicable at a TPH concentratm o� f�710 PPn^ (J �Py/pA1 <br /> Vt. STAFF RECOMMENDATION/CONCLUSION I I Ie CLQ- •tA!/V't t.��`-""" I'� "�QD��X/�QI� (�� <br /> 1. Are BTX & E or TPH Concentratio > Allowable Levels Yes o _ \ 7QS�N`� <br /> 2 Recommend SiteClosure es o If Yes, Refer to Site Mitigation for Evaluation e_1vwNu w�V.��(_Yy�r!� <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES O <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 50 (UGTWKSHT)\5/94 <br />