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SAN,—.Qu,,. COUNTY PUBLIC HEALTH SERVICES/ENVIRONMrRfAL HEALTH DIVISION <br /> I' UGST WORKSHEET FOR SITE CLOSURE EVALUATION _ o <br /> mi Y (� ATE <br /> B. ' ' O i i �/��90 EEPS CODE / S <br /> a /0(),) UEL TYPE <br /> GLI.... <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? es o ermit # - acility Status Code 9 oc.Soil/GW Cont es o ' <br /> umber of Tanks at facility ge of Tanks(if available) <br /> ype of Tank Leel brgl ngl Dual <br /> III. TANK HISTORY <br /> Jas Tank tested? as Vllf o ailed precision test es o <br /> If yes, give dates) <br /> Jas a repair made to the tank system? Yes No f yes, what was repaired? " <br /> denJas repair done under inspection? <br /> as o ere soil samples analyzed? e o TXE PN-G PH-D b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfill nown ' ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es 1 o epth to Ground Water of/Year <br /> verage Arcual Precipitation = 4 0-25 <br /> -Site Wells) as o umber 8 Type Irr am ub <br /> istance to Wells) from Tank S core S core S core <br /> ft; ft; - —ft U if pts ifpts C pts <br /> 0 f <br /> V. Site Feature - Leaching Potential Analysis R ondition R ondition R ondition <br /> E is it <br /> E is met E 's met <br /> inimum Depth to groundwater from the Soil Sample (feet)5 >100 <br /> 1-100 4 25-50L1 <br /> ractures in subsurface (applies to foothills or mountain areas) Q <br /> None J Unknown resent <br /> verage Arcual Precipitation (inches) <br /> xxxx <10 9 10-25 xxxxxx 26-401 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) <br /> None Unknown resent <br /> ique site features: Recharge area, coarse soil, nearby wells. <br /> At least 4ore than <br /> xxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS + + <br /> -/ <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or less <br /> A.1- 01�J��i 8T X E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NAi <br /> ample Result: ASOLINE 1000 <br /> IMUM ALLOWABLE TPH LEVELS (PPM) 100 10 <br /> TPH IESEL 10,000 1000 <br /> 100 <br /> OOTNOTES: ***If documented soil and/or ground water contamination is present do not complete the leaching <br /> analysis. (i.e., site is currently on UGT Contamination list for soilground water.or r. Potential <br /> ) depth <_1 If depth is > 5 ft. and < 25 ft., score 0 points. If de ) <br /> 1 If precipitation is > 40 inches, score 0 points. P 'S ft., do not use table. <br /> 13, Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 14 A)) x GQ <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes I LO I <br /> 2. Recoatnend Site Closure es o if Yes, Refer to Site Mitigation for Evaluation <br /> 6441 et4 <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR � c WC <br /> R � - <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> HREFERRED / / ATE CLOSURE LETTER MAILED <br /> EH 23 80 (UGTWKSHT)\5/90 <br />