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H tERVICES/ENVIROMME14TAL 01VISION DATEI <br /> SAN IOAOUI14 Y PUBLIC HEALT ATION <br /> UGST WORKSHEET FOR SITE CLOSURE EVALU <br /> SWEEPS CODE <br /> NAME OF FACILITY C!_N <br /> L <br /> TANK ID <br /> ADDRESS t <br /> a ' <br /> TANK SIZE FUEL TYPE L) e2 <br /> II_ GENERAL SITE HISTORY <br /> Doc.Soil/GW Cont�Ye5 No <br /> Is permit current? Yes <br /> Facility St <br /> NO Permit 9 <br /> s jSngL Dual <br /> I . Type of TankjSteeLj3&FbrgL� <br /> Age of Tank (7if -v-iL-bL-�� <br /> Number of Tanks at facility <br /> III. TANK HISTORY <br /> Was Tank tested?I Yes No Failed precision No if Yes, <br /> Was a repair made to the tanksystem? Yes No If yes 1, what was repaired?I - <br /> Was repair done under inspection? YesI No were tL� <br /> Samples analyzed? Yes No STXEJ IT <br /> _ <br /> IType of failure/discharge 1, catastrophic long-term Leakageoverfill unknown) lother- <br /> 1 <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA. FOR"LF-ACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes Na Depth to Groundaterl5blwiyea' r 26 J Average Annual Precipitation A= 1.4 �10-251 <br /> On-Site WellYes Y/es <br /> Number t Type ' Irr Dom jPub S: Score S Score S Score <br /> 9 <br /> Distance to WeLL(s) fromTank ft; ft; ft C 10 pts C 0 iPts C pts <br /> 0 if f O if <br /> R condition R condition R condition <br /> 5 <br /> V. Site Feature Leaching Potential Ana Lys is i.s met is met is met <br /> (feet) 25-50\1 <br /> . >100 <br /> minimum Depth to groundwater from the Soil Sample �22—I I <br /> -------- Unknown Present <br /> Fractures in subsurface (applies to foothills or mountain areas) None Present <br /> xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> Average Annual Precipitation (inches) <br /> L <br /> conduits which increase vertical migration <br /> Man-made -or"' None Un"---,- <br /> M2d <br /> lof Leachate 0-e-, septic system, water�weLLs, ponds) <br /> At Least more than Of <br /> 01iUnique site feature.s: Recharge area, coarse soil, nearby wells. xxxxxx None one ik one <br /> + <br /> COLUMN T OTALS>>>TCTAL POINTS <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS49 pts, or more I 41 - 48 pts I 4 <br /> . - <br /> 81-TX I E S [�T] 11 E <br /> MAXIMUM ALLOWABLE a <br /> -T-X-E LEVELS (PPM) 1 50 <br /> 50 So 3 3_ NA%3 <br /> ' <br /> 10 <br /> Er4ASOL:1:1N:1E 1010110 100 <br /> SampLe Resutr�"10 --i_1_' <br /> r. 6 MAXIMUM ALLOWABLE TPH LEVELS (PPM) DIESEL 0 <br /> .1 10,000 1000 100 <br /> 1 4, TP H [D DIESEL <br /> I�t <br /> aching potential <br /> FOOTNOTES: ***If documented soil and/or ground water contamination present, do not compkete the cm. , <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground w <br /> \1 if depth is > 5 ft. and < 25 1 <br /> -�t., score 0 points. if depth ­5 ft., do not use table. <br /> %2 If precipitation is ;- 40 inches, score 0 points. of 10 ppm (gasoline) or IOU ppm (dieset <br /> \3 Levels for BTX&E are-not applicable at a 'TPH concentration <br /> 4A <br /> J,A-D q-4�0 <br /> 7r�114 a;- <br /> VI. STAFF RECOMMENDATION/CONCLUSION P 1 13, -;�_ <br /> S4V�K P <br /> 1. Are BTX & E or TPH Concentrations > Allowable LeveLs 1*YeS Na�K <br /> I — Yes <br /> - ion <br /> Refer�to Site Mitigation o <br /> 7Y 1 7-� <br /> *If Yes, Refer to Site mitigation for Evaluation <br /> 2. Recommend Site CL11-1- <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR ENIOR <br /> No <br /> CLOSURE YES NO (REFERRED TO SITE MITIGATION FOR EVALUATIONIYES1 I <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLCS <br /> FDATE REFERRED-1 6 IDATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR 0 <br /> EVALUATOR <br /> =H 23 80 (UG",WKSHT)\5/90 <br />