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�d_Nta- <br /> SAA%mPr.i6...: COUNTY PUBLIC HEALTH SERVICES/ENVIRON)rEOAL HEALTH DIVISION <br /> 1' UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE I V /7 ,9 O <br /> AME OF FACILITY I , l? D/ / SWEEPS CODE <br /> 3 <br /> DRESS D �! TANK I•D T# 317 - 1175_ <br /> D <br /> ANK SIZE /a UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? es o ermit S - ** <br /> acility Status Code �' oc.Soil/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) S ype of Tank ISteet brgl ngl Dual <br /> 1I1. TANK HISTORY <br /> Jas Tank testedT es 00 _lFailed precision test ? es o !f yes, give date(s) <br /> Jas a repair made to the tank system? Yes No f yes, what was repaired? <br /> Jas repair done under inspection? as o ere soil samples analyzed? es o TXE PH-G PH-D b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfill nown ther: <br /> IV. REMOVAL HIS (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es o epth to Ground Water '� of/Tear <br /> g(� C(�; verage Annual Precipitation = 4 0-25 <br /> )n-Site Well(S) es o umber 8 Type !rr am ub <br /> istance to Well(S) from Tank ft• S core S core S core <br /> ft; ft C 10 pts C 9 pts C pts <br /> 0 if 0 if O f <br /> Site Feature - leaching Potential Analysis R ondition R audition R axiition <br /> y E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sanple (feet) >100 1-100 <br /> 25-50•L <br /> ractures in subsurface (applies to foothills or mountain areas) None <br /> Unknown resent <br /> verage Annual Precipitation (inches) xxxx 00 9 10-25 KXXxxxx 26-4012 <br /> Ian-Made conduits which increase vertical migration <br /> Df leachate (i.e., septic systems, water wells, ponds) None <br /> Unknown resent <br /> nique site features: Recharge arca, coarse soil, nearby wells. <br /> At least ore than <br /> xxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS �j + O�� + �� <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> ig o f # I i���,✓we- M-7 <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 11 SO 50 50 =TX <br /> . NA1 <br /> Sample Result: <br /> ASOLINE 1000 100 10 <br /> X 461 1t � M ',7 TPH IMUM ALLOWABLE TPH LEVELS (PPM) <br /> IES' 10,000 1000 100 <br /> OOTNOTES: ***If documented soil and/or ground water contamination is present, do not catplete the teaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> Ll If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> ,L2 If precipitation is > 40 inches, score 0 points. <br /> L3 Levels for BTXBE are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION C <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o 7'P,A)1':\S ( — �a�-� <br /> 2. Recommend Si to Closure es o �+��C i Si �1 <br /> If Yes, Refer to Site Mitigation for Evaluation ,C.`J"' <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIORU4.1 O�L7 <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />