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SAN ,)a=10UNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL �1H DIVISION <br />I UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE! <br />NAME OF FACILITY I I�"' / .� ISWEEPS CODE 3 <br />ADDRESS I 3 F, , (�� a } �) ! TANK [Q #1 ' - f7-6Y-6 <br />TANK SIZE FUEL TYPE! <br />II. GENERAL SITE HISTORY <br />Is permit current? IYes i �No !Permit1 - Facility Status Code` IDoc.SoiL/GW ContlYesl INo <br />Number of Tanks at facility Age of tanks(if available)! Type of Tank ISteel I (Fbrgll ISngl1 Ouali <br />III. TANK HISTORY <br />Was Tank tested? IYes lNol !failed precision test ? <br />Yes+ if yes, give date(s)� <br />Was a repair made to the tank system? Yes gol if yes, what was repaired? <br />Was repair done under inspection? Yes !Mol Were soil samptes analyzed? Yesf !Mol <br />BTXEI ITPH-GI ITPH-fly }Pb/EQBI <br />Type of failure/discharge !catastrophic! !tong -term Leakagei IoverfiILI lunknownl lother: <br />IV. .REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALT515) <br />Soil Samples Received Yes <br />INoI !Depth to Ground Water !Ref/Year !Average Annual PrecipitacionlA=114 <br />110-25 <br />On -Site WeLLCs)iYes lNol (Number & Type1 IIrrI 10.1 Pub! <br />S <br />C <br />O <br />R <br />c <br />Score <br />10 pts <br />if <br />condition <br />his met <br />S <br />C <br />0 <br />R <br />c <br />Score <br />9 pts <br />if <br />condition <br />is net <br />S <br />C <br />0 <br />R <br />E <br />Score <br />5 pts <br />if <br />condition <br />is met <br />Distance to WeIL(s) from rank ft; ft; ft <br />V. Site Feature - Leaching Potential Analysis <br />Minimum Depth to groundwater from the SoiL SamoLe (feet) <br />>100 ' j51-100 i <br />175-10\1 <br />Fractures in subsurface (applies to foothills or mountain areas) <br />I None l Unknown i <br />Present <br />Average Annuat Precipitation (inches) <br />lxxxxxxl <br /><10 <br />9 j 10 -?5 <br />lxxxxxxxl <br />26-40\2 <br />jMan-Made conduits which increase vertical migration <br />Iof leachate (i.e., septic systems, water wells, ponds) <br />( None <br />( <br />Unknown <br />ji <br />jPresent <br />Unique site features: Recharge area, coarse soil, nearby wells.I <br />xxxxxxk <br />Nose <br />i <br />if <br />At Least <br />onei <br />More than <br />one <br />S A4 TO44- <br />tOLUMN TATA , >TOTAL POINTS <br />1 <br />Sample Res It. <B T X OR E) <br />a / j <br />RANGE OF TOTAL POINTS <br />49 pts or more 41 - 48 pts <br />G0 pts or Less <br />MAXI1%1M ALLOWABLE S -t -X -E LEVELS (PPM) <br />aT <br />1 <br />X i c i a T X <br />1 501 50+ 50 .3 1_3 I 1_ <br />'E <br />1 1. <br />i� <br />1 <br />NA\3 <br />SamplIGASOLINE <br />eM �esult- <br />ampt !MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br />TPH IDIESEL <br />1000 I 100 <br />10 <br />10,000 I 1000 <br />I 100 <br />FOOTNOTES: " T f documented soil and/or ground water contamination is present, do not complete the Leaching potential <br />analysis, (i.e., site is currentty an 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 > Q inches, score 0 points. <br />\3 Levels for 3TX&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 3e E or TPH Concentrations > ALLowable Levels ("Yes! Nof OL T wCd <br />P, Y_3 -Y <br />j 2. Recommend Site CLosurelYesi Not X _*If Yes,Refer to site Mitigation for _valuation) <br />VII. REVIEW EVALUATION - TO 3E COMPLETED aY A SUPERVISOR/SENIOR <br />:0NCJR WITH STAFF 2ECOMMEWATION FOR CLOSUREIYES} iNOj 1REFERRED -0 SITE MITIGATION FOR _iIALUATIONIYESI 'MCI j <br />TATE REFERRED / / jDATE CLOSURE LETTER MAILEQ1 <br />TAME OF <br />IVALUATORI <br />EH 23 30 (UGTWKSHT)\5/90 <br />