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1. M <br /> 'COUNTYRPU8LIC:HEALTH SERVICES/ENVIROki .;EALTH DIVISION <br /> r; r <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUh : url ATE <br /> AME OF FACILITY r�� �� <br /> �T/ �/7xG 0u t WEEPS CODE �� <br /> DRESS <br /> ANK ID <br /> ANK SIZE / OD U UEL TYPE ` <br /> ir. GENERAL SITE HISTORY'. <br /> I; Is permit current7 es� o ermit IV - *} <br /> acility Status Code q9 oc.Soil/GW Cont es o <br /> t umber of Tanks at facility <br /> ee of Tanks(if available) ypa'of Tanis teel': Fbrgl ngl Dua! <br /> Ill. TANK HISTORY7 /Gw <br /> Jas Tank tested? as J o ailed precision test ? es o If yes, give date(s) <br /> Jas a repair made to the tank system? es No f yes, what was repaired? <br />.• as repair done under inspection? e 40 ere soil samples analyzed? es 0 TXE PH-G PH-0 b/EDB <br /> ype of #allure/discharge atastrophic Long-term leakage verfiI. known Cher: <br /> IV. REMOVAL HISTORY (ATTACH INSP TION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es o epth to Ground Water �j of/Year verage Arcual Precipitation <br /> -Site WeLI(s) es 0 umber & Type <br /> Ir am ub 1 <br /> 5 3core S core S core <br /> istance to Well s) from Tank ft; _,�ft; ft C 0 pts C pts C pts <br /> _' 0 if 0 if 0 f <br /> R ondition R condition R rondition <br /> Site Feature - leaching Potential Analysis E is met E is met E is met <br /> ` inimtm Depth to groundwater frau the Soil Saupte (feet) >100 1-100 25-SOL <br /> ractures in subsurfaceil'(applies to foothills or mountain areas) None unknown resent <br /> _ <br /> Average Annual Precipitation (inches) xxxx 410 9 10-25 xxxxxx 2b-40]2 <br /> an-Made conduits whichs�increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown >resent <br /> ique site features: Recharge area, coarse soil, nearby wells. <br /> At least lore than <br /> xxxx None one one. <br /> COLUMN TOTALS>>>TOTAL POINTS + t <br /> ample Result: (B T X DA E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> B 1 T IX E 0 T X E <br /> MAXIMUM ALLOWABLE B-T-X-E.LEVELS (PPM) t 50 50 50 .3 .3 1. .1. NAL3 <br /> aimpie Result: ASOLINE 1000 100 10 <br /> IMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not canptete the leaching potential <br /> analysis. (i.e., site is currently an UGT Contamination List for soil or ground water.) <br /> 11 If depth is > 5 ft. and < 25 ft., score 0 points. if depth <=5 ft., do not use 'tabLe. <br /> L If precipitation is -40 inches, score 0 points. <br /> L Levets for BTX&E are not applicable at a TPH concentration pf 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1, STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes 0 <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 VES 0EFERRED TO SITE MITIGATION FOR EVALUA7tON ES O <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF t <br /> =VALUATOR <br /> EH 23 00 (UGIWKSHT)\5190 a <br /> ., J <br /> __-_T ..__-— __:- - <br />