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SAN 3QACUIN G r rY ^-IC','HEALTH SERVICES/EHVIROHMEIN HEA I BION �? q <br /> yI 'T wwRKSHEET FOR SITE CLOSURE EVALUATION ' ATE �� f 11 <br /> f ,iME OF FACILITY 5/ Fi1�2 P A S SWEEPS CODE <br /> D7DRESS 8-7 ,5 O �e TANK <br /> TD # - <br /> LANK SIZE UEL TYPE /~ , <br /> HT1. GENERAL SITE HISTORY <br /> s permit current? ' es o ermit # Sc W ty Status Code oo.Sol t/GW Cori es o <br /> umber of Tanks at ,facitity ge of Ta�ks(if availabte) V ype of Tank• Leel brgl ngl 3,DuaE <br /> ITI. TANK HISTCRT <br /> ns Tank tested-?- es a ailed precision test 7 es o If yes, give dates) <br /> as a repair shade to the tank system? es No I f yes, chat was repaired? <br /> as repair done under inspection? es o ere soil samples analyzed? as o TXE PH-G PH-D I b/E08 <br /> atastrophic Long-term Leakage verfill nknown Cher: <br /> ype of failure/discharge <br /> I. 4 <br /> IV, REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITU DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> ii <br /> wit Samples Received es a epth to Ground Water of/Year verage Annual Precipitation = 4 0-25 <br /> I -Site WeLL(s) es o umber b Type Irr . om ub <br /> S core S core S. core <br /> �! istance to Wells) from Tank tt; ft; fc C 0 pts C pts C.- pts <br /> r 0 if 0 :4LoMi <br /> if; 0 f . <br /> i <br /> R andiLion Rion R anditian <br /> Site Feature - Leaching Potential AnalysisE is met E E s met <br /> inim-m Depth to groundwater from the Soit Saople if'eet) >100 1-t00 25-50\) <br /> ractures in subsurface (applies to foothit[s mountain areas) None Unknown Dresent <br /> E %verage Annual Precipitation (inches) xxxx <10 9 10-25 xxxxxx 25-40\2 <br /> on-made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) Unknown resent <br /> pique site features: Recharge area, coarse soil, nearby weLLs. iore than <br /> xxxx None ' one <br /> j COLUMN TOTALS»>TOTAL POINTS s 3 3 <br /> a [e Result; (B T % OR E) <br /> WRANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or Less <br /> = r 16 P p r-50 �9 <br /> 7:01 `� 7PPnn '� X`4/0/ NAXIMLH ALLOWABLE B-T-X-E LEVELS (PPM) B 50 50 50 .3 I.T <br /> 3 1. 1; HA\3 <br /> " ample Result: ASOLIN£ 1000 100 10` <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> R <br /> COTHOTES: `""If documented soil and/or ground'�water contamination is present, do not complete the Leaching !potential <br /> analysis. (i.e., site- is currencty 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,11score 0 points. <br /> \3 Levets for BTXLE are not applicable at a TPH concentration of 10 ppm (gasotine) or 100 ppm (diesel). <br /> 71. STAFF RECOWENDAT.ION/CONCLUSION <br /> 1. Are BTX & E or, TPH Concentrations > Attowa Le Levels res o <br /> �! 2. Recommend Site Closure es o If Yes; Refer to Site Mitigation for Evatuation <br /> 7111. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/! HIOR <br /> CONCUR WITH STAFF RECCHMEHDATION FOR CLOSURE rES 0 EFERRED TO-SITE MITIGATION FOR EVALUAi10NES 17-to <br /> i <br /> ATE REFERRED ! l / ATE CLOSURELETTERMAILED ¢ / <br /> i, JAME OF <br /> ;VALUATOR J <br /> I� EN 23 80 (UGTWrSHT)\5/90 <br />