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4U�WCRKSHEETBLIC HEALTH SERVICES/ENVIRONMENTAL HEALi <br /> SAM JpAaJiN ISION FOR SITE CLOSURE EVALUATION <br /> SWEEPS CODE <br /> .� sh <br /> 5�• - TANK ID # 8' <br /> TAsiuE <br /> ::5'0 0 FUEL TYPE Lv A S 1 G <br /> ll_.-{BNMAL SITE HISTORY <br /> ' Facility Status Code DOC.So WGW Cont Yes No <br /> Is..par�t asrerrt? Ya No <br /> permit # <br /> oAber af.Tanks at facility <br /> Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Oual <br /> III«TA1YC YISTORY � <br /> Yes.Tut.tested? Yes Ho Failed precision test ? If yes, give dt <br /> Yes No ae s) / <br /> Was a reir=de to the tank system? Yes No Iif yes, what was repaired? <br /> pa <br /> Was rjWfr dont urder inspection? Yes No Were soil samples analyzed? Yes No Dt Pb/EDB <br /> Type of faiture/discharge catastrophic long-term leakage overfill unknown other: <br /> IV_ REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE OETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil samples Received Yes No Depth to Ground Water Ref/Year Average Annual Precipitation A= 14 10-25 <br /> Ort-site Wells) Yes No Number & Type Irr DomPub <br /> S Score S Score S Score <br /> Distance to W@LL(S) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R condition R condition R condition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet) / — +p t() >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) O None Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9 1 10"25 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) (� None Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At Least More than <br /> xxxxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS 301 + <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> B T X E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH DIESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not the leaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> \1 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 /> \3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No <br /> 2. Recommend Site Closure Yes No *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 YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 a0 (UGTWKSHT)\5/90 <br />