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SAN'-4dAOUiee COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> I' UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE 6 p <br /> ' /7 7 Q <br /> iAME OF FACILITY � D�• # / !QSWEEPS CODE <br /> DRESS a D C In / <br /> ANK'4D fl <br /> ANK SIZE D D O IFUEL TYPE �i Q <br /> 11. GENERAL SITE HISTORY <br /> *w <br /> Is permit current? as o ermit aY - acility Status Code oc.Soil/GW Cont es o <br /> umber of Tanks at facility T ge of Tanks(if available) ype of Tank reel brgl ngl Dual <br /> III. TANK HISTORY <br /> Jas Tank tested? es I o I ailed precision test ? es 140 If yes, give dates) <br /> Jas a repair made to the tank system? es NoIV f yes, what was repaired? 1 nl ���,�� <br /> R C- `L�tc moi• � <br /> Jas repair done under inspection? as 40 ere soil samples analyzed? e o TXE PH-G PH-D b/EDB <br /> ype of failure/discharge atastrophic long-term leakageverfill nown they: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es I o epth to Ground Water ' of/YearS verage Annual Precipitation a 4 0-25 <br /> -Site Well(S) es o umber $ Type Irr om ub <br /> S core S core S core <br /> istance to Well(S) from Tank ft; ft; ft C 10 pts C 9 pts Cp is <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) >100 1-100 25-50L <br /> ractures_in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Amual Precipitation (inches) KXXXXX <10 9 10-25 xxxxxxx 26-402 <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 4ore than <br /> xxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS + + <br /> [ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> jd_AAA� OC <br /> X**t c , t7 6)Cl B 1 T X E B <br /> JT X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA13 <br /> Sample Result: ASOLINE 1000 100 10 <br /> 1MUM ALLOWABLE TPN LEVELS (PPM) <br /> TPH IESEL 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 /> L if depth is > 5 ft. and < 25 ft., score 0 points. If depth ­5 ft., do not use table. <br /> _\2 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 /> ---------------- <br /> V1. STAFF RECOMMENDATION/CONCLUSION ( N >v-' <br /> 1. Are BTX & E or TPN Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure es oIf 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 VESI 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EN 23 80 (UGTWKSHT)\5/90 <br />