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I • l� l ~~ <br /> SAH JOAf,, ) CCXIH,. PUBLIC HEALTH SERVICES/ENVIRONMENTf ALTs. -1VISION <br /> I Y� UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE Z_Iz_9 Z <br /> AME OF FACILITY EEPS LODE 'Z 3 <br /> DDRESS ANK ID # �&6 Z <br /> ANK SIZET <br /> i UEL TYPEfi <br /> p,� 4,6,- <br /> 11. GENERAL SITE HISTORY <br /> w♦ <br /> :s permit current? e5 o ermit # acility Status Code oc.Soil/GW Cont es o <br /> umber of Tanks at fecflity Nige of Tanks(if available) Itype of Tank reel I Fbrgi ngl I Dual <br /> 111. TANK HISTORY <br /> as Tank tested? es o ailed precision test 7 esa If yes, give date(s) <br /> Jas a repair made to lthe tank system? IYes No f yes, what was repaired? <br /> ns repair done under' inspection? es a ere soil samples analyzed? es to TXE _TP I PH-O b/EDB <br /> ype of failure/discharge atastrophic long term leakage verfill noxa ther: <br /> lll <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received eso epth to Ground Water of/Year verage Annual Precipitation k= 4 10-25 <br /> Din-Site Weti(s) es ki o umber & Typeirr om <br /> S core S Score 5 core <br /> istance to Wells) from Tank _f t; ft; ft C 10 pts C 9 pts C i pts <br /> 0 f 0 if 0 f <br /> R ondition R ondiLion R ondition <br /> V. Site Feature - Leaching Potential Analysis E s met E is met E s met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 25-5011 <br /> ractures in subsurface (appiies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) xxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> f leachate Ci.e., septic systems, water wells, ponds) None Unknown 31resent <br /> Inique site features: Recharge area, coarse soil, nearby wells. At least lore than <br /> �xxxxxj 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 /> ►V`J� ��`� B T x E B T x E <br /> t MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1, 1. NA\3 <br /> Sample Result: A <br /> GASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE 7PH LEVELS (PPM) <br /> N h TPH-&: IESEL 18,000 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 /> \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 TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH'Concentrations > Allowable Levels <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> ViI. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> ,ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />