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f <br /> SAH JOAG4,,pCOU>,.. PUBLIC,HEALTH SERVICES/ENVIRONMENTAL LTi. sVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE 2_I _19 Zi <br /> AME OF FACILITY iSWEEPS CODE /Z_3 7. <br /> DORESS TANK ID # <br /> TANK SIZE 26M UEi TYPE ,o �/B/ g <br /> 11. GENERAL SITE HISTORY' <br /> wr <br /> Is permit current? eso ermit # acitity Status Code oc.Scil/GW Cont os I1 I o <br /> umber of Tanks at facitity ge of Tanks(if available) ype of Tank teal Fbr9ln9t I Dual <br /> Ill. TANK HISTORY <br /> as Tank tested? es o ailed precision test ? es a if yes, give date(s) <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> ns repair done under inspection? es 1 4I <br /> aL <br /> ere soil samples analyzed? es to TXE PH-G PH-D b/EDB <br /> ype of failure/discharge atastrophic, g term Leakage verfitl nknown ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es I IN01 epth to Ground Water of/Year verage Arcual Precipitation = 4 IQ 25 <br /> Site Weil(s) es o umber & Type Irr ae ub <br /> S Score S Score 5 3core <br /> istance to Well(s) from Fank ft; ft; ft 'C 10 pts G 9 pts C 5 pts <br /> :'0 if 0 if 0 if <br /> R ondition R condition R ondi tion <br /> 0. Site Feature - Leeching Potential Analysis E is met E is met E s met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) xxx.xxx <10 9 10-25 xxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> Inique site features: Recharge area, coarse soil, nearby wells. At least lore than <br /> xxxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS + + <br /> ample Result: (a T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> :o33?r4v�x <br /> O T X E 11 X E <br /> MAXIMUM ALLOWABLE B-T-%-E LEVELS (PPM) 1 50 50 50 .3 J.T <br /> 3 1. 1. NA\3 <br /> ample Result: ASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> tJ 60 InTPH;,G IESEL. 10,000 1000 100 <br /> OOTNOTES: ***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 It 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 /> V1, STAFF RECOMMENDATION/CONCLUSION <br /> 1, Are BTX & E or TPH Concentrations > Allowable Levels hes 1. o° <br /> 2. Recomnend Site Closure 1Yes o 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 ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> RTE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> .VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />