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1 <br /> SA"dAA0U1N COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE4AM <br /> E OF FACILITY /'O'n <br /> / 'n WEEPS CODE / 7_5- <br /> DRESS 7_5- <br /> DRESS ,�, // // t <br /> �L�GG- �G/7. AHK'W�/ 3 '��7— " U 3 <br /> ANK SIZE UEL TYPE rQ C2a � <br /> Il. GENERAL SITE HISTORY <br /> ** <br /> s permit current7 es o ermit # - acility Status Code 9 oc.Soil/GW C t es o <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tank teel brgL ngl Dual <br /> 111. TANK HISTORY <br /> as Tank tested? eso ailed precision test es o If yes, give dates7/ 3 / 7 <br /> Jas a repair made to the tank system? Yes No kvIlf yes, what was repaired? <br /> Jas repair done under inspection? es 40 ere soil samples analyzed7 es o TXE PH-G I kPH-D_Ib/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfill nown they: <br /> 1V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es 0 epth to Ground Water � of/Year �� ; verage Annual Precipitation <br /> -Site Well(s) es o umber 8 Type Irr oo ub <br /> S Score S Score S core <br /> istance to WeLL(S) from Tank ft; ft; ft C 10 pts C 9 pts C pts <br /> 0 if 0 if 0 f <br /> V. R ondition R condition 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)YO 41 >100 1-100 25-50L <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 Kxxxxxx 26-40i <br /> Ian-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> pique site features: Recharge area, coarse soil, nearby wells. At least 40re than <br /> xxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS ; + <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or Less <br /> B 1 T IX E 8 T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 1501.. NAI <br /> Sample Result: "JESEL <br /> 1000 top 10 <br /> IMUM ALLOWABLE TPN LEVELS (PPM) <br /> TPH 10,000 1000 100 <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 /> J1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do rat use table. <br /> L2 if precipitation is > 40 inches, score 0 points. <br /> L Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes To <br /> F-7( <br /> 2. Recommend Site Closurees o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES FERRED TO SITE MITIGATION FOR EVALUATION ES TO <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />