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SAN .t0A0U&NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL 10-H DIVISION <br />I UGST WORKSHEET FOR SITE C!.0SURE EVALUATION DATE <br />NAME OF FACILITY�"� %+ SWEEPS CODE! a 3 1 7" i <br />ADDRESS I� e t y G) S--� G ' 37 TANK ID #� - i s C�t <br />TANK SIZE - 1FUEL TYPE- <br />11. GENERAL SITE HISTORY <br />is permit current?(Yes! No !Permit #I - Facility Stair -is Code �1Ooe.SoiL/GW Cant�Yes No) <br />Number of Tanks at facilityi 6) Age of Tanks(if available)( Type of Tank1Steel 1 1Fbrgl` ISngII Ouall <br />III. TANK HISTORY <br />Was Tank tested? Yes ,No' jFailed precision test ? Yes �me If yes, give date(s)i <br />Was a repair made to the tank system?IYesl Ne ,If yes, what was repaired? <br />Was repair done under inspection? , Yes ! (No! Were soil samples analyzed? Yes �No' <br />BTXEJ {TPH-GI !TPH-01 IPb/EDB( <br />r <br />c <br />Type of failure/discharge catastrophic{ long-term leakage (overfill `unktaun� father: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE OETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />Soil Samples Received IYes <br />�No <br />Depth to Ground Water !Ref/Year{ Average Annual Precipitation�A= <br />14 10-25 <br />On -Site WeIL(s)lYes INo INumiber b Type; �Irr` �Oom1 Pub <br />S <br />C <br />fl <br />R <br />E <br />Scare <br />10 pts <br />if <br />condition <br />'is met <br />S <br />C <br />Q <br />R <br />_ <br />Score <br />9 pts <br />if <br />condition <br />is met <br />S <br />C <br />o <br />R <br />E <br />Score <br />5 pts <br />of <br />condition <br />is met <br />Distance to WeLL(S) from Tank ft; ft; ft <br />V. Site Feature - Leaching Potential Analysis <br />,[Minimum Depth to groundwater from the Soil Sample (feet) 56— <br />! .IGO <br />i 151-100 <br />15-50\1 <br />Fractures in subsurface (applies to foothills or mountain areas)None <br />I Unknown <br />4 <br />(Present <br />Average Annual Precipitation (inches) <br />jxxxxxx} <br /><10 <br />9 <br />10-25 <br />Ixxxxxxx+ <br />26-40\2 <br />(Man -Made conduits which increase vertical migration <br />Iof leachate (i.e., septic systems, water wells, ponds) <br />Name <br />Unktnown <br />Present <br />Unique site features: Recharge area, coarse soil, nearby sells. <br />xxxxxx <br />� None <br />j � � <br />l <br />At leash <br />one` <br />(More than <br />one <br />COLUMN TOTALS> >TOTAL POINTS <br />l Q <br />Sample Resu,it: (3 T X OR E) <br />T A' <br />M 1 a L- - ��y �, <br />RANGE OF TOTAL POINTS <br />49 pts or more <br />l 41 - 48 pts <br />pts or Less <br />MAXIMUM ALLOWABLE 3 -T -X -E LEVELS (PPM) <br />3 T <br />1i 50� <br />X 'e <br />50+ 50 <br />8 T <br />I .3 .3 <br />X a <br />1_1 1. <br />11 NA\3 <br />Sample Result: IVi)Tptl0 <br />Kw�- * &69- <br />1) A. ® V TAH <br />iGASOI-INE <br />MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br />(DIESEL <br />1000 <br />100 <br />10 <br />I 10,000 <br />I 1000 <br />100 <br />FOOTNOTES: " Tf documented soil and/or ground water contamination is present, do not complete the l <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 death c5 ft., do not use table. ' <br />\2 If precipitation is > 40 inches, scare 0 points - <br />\3 Levels for 3TX&E are not applicable at a TPH tration of 10 ppm (gasoline) or 100 ppm (diesel). <br />1 <br />VI . STAFF RECOMMENDATION/CONCLUSION 1^ j f h ao dv-rO <br />Are 3TX 3 ° or TPH Concentrations >`ALLLowable Levels 'Yes :No} ( �j, P. "3 ! �`�✓ <br />2. Recommend Site ClosureiYesj �No -4L-if Yes, Refer to Site !litigation for =valuation <br />VII. REVIEW EVALUATION - TO SE aWLETED SY A SUPERVISOR/SENIOR <br />ONCUR WITH STAFF RECOMMENDATION FOR CLOSUREIYESi iNO1 iREFE-4REO TO SITE MITIGATION FOR EVALUATIONIYES1 ANO' I <br />ATE REFERRED I / / DATE CLOSURE LETTER wAILED# / / <br />AME OF <br />VALUATOR( <br />_H 23 30 (UGTWKSHT)\5/90 <br />