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SAN COUNTY PUBLIC HEALTH SERVICES/ENVIRONME'#Mtly CALTH DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY C-i O� S+L)CK-f-DVI L.,LLSWEEPS CODE �$ l <br /> fDRESSZZ Ma 1. _.f- ANK 10 # - <br /> ANK SIZE 10W0 UEL TYPE C�iSollws� <br /> II. GENERAL SITE HISTORY <br /> Is permit current? es o ermit # lFacitity Status Code oc.Soil/GW Cont as o <br /> umber of Tanks at facility ?J ge of Tanks(if available) I Za ype of Tank teel Fbrgl ngl Dual <br /> II1. TANK HISTORY <br /> Jas Tank tested? es I V�o ailed precision test ? hs o If yes, give date(s) <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> Jas repair done under inspection? eso ere soil samples analyzed? es TXE 8 -D _b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfill noun er: <br /> IV. REMOVAL HISTORY (ATTACH INSPECT)ON REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es o epth to Ground Water d0 of/Year Spy ; 19% verage Annual Precipitation k= 4 0-25 <br /> -Site Wells) es o umber & Type Irr om ub <br /> S Score S Score S core <br /> istance to Well(S) from Tank t; ft; ft C 10 pts C 9 pts C pts <br /> 0 if 0 if 0 f <br /> R ondition R condition R condition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet)r —go ligI >100 1-100 O 25-5011 <br /> ractures in subsurface (applies to foothills or mountain areas) None q Unknown resent <br /> verage Annual Precipitation (inches) xxxxx <10 9 10-25 xxxxxxx 26-40,12 <br /> Ian-Made conduits which increase vertical migration <br /> Df leachate (i.e., septic systems, water wells, ponds) None Unknown resent, <br /> pique site features: Recharge area, coarse soil, nearby wells. o At least 4ore than <br /> xxxx None -1 one one <br /> COLUMN TOTALS>>>TOTAL POINTS O + + <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> Qf1'h 8 <br /> B T X E B JT X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 SO 50 .3 .3 1. 1. NAS <br /> Sample Result: ASOLINE 1000 100 10 <br /> TOO.O TPH IMUM ALLOWABLE TPH LEVELS (PPM) <br /> e 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 /> 11 if depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> L if precipitation is > 40 inches, score 0 points. <br /> 13 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION ,. <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes 1001 <br /> 2. Recomnend Site Closure es I II0 If Yes, Refer to Site Mitigation for Evaluation <br /> VI1. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE fES1 0 I EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / 9 / 9 ATE CLOSURE LETTER MAILED <br /> AME OF <br /> -VALUATOR �, — <br /> EH 23 80 (UGTWKSHT)\5/4b <br />