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avnrvtn .wr..t r�ot.t. nt„t.In Z1tKV1"Z)/tNV1KUNMtNIAL HEALTH DIVISION <br /> 1 WORKSHEET FOR SITE CLOSURE EVALUATION <br /> NAME Of FACILITY r r q SJ 7 SWEEPS / O <br /> ADDRESS TANK ID it j <br /> TANK SIZE 4� OC FUEL TYPE <br /> II. GENERAL SITE HISTORY <br /> *r* <br /> 1s permit current? Yes No N11Permit - Facility Status Code CHDoc-Soft/GW Cont Yes No <br /> Number of Tanks at facility Age of Tanks(if available) 6"A Type of Tank Steel Fbrgl Sngl Dual <br /> 111. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test t Yes No If yes, give date(s) <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? <br /> Was repair done under inspection? Yes No Were soil samples analyzed? Yes No BTXE TPN-G TPH-D Pb/EDB <br /> Type of failure/discharge catastrophic tong-term leakage overfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Ground Water Ref/Tear Average Annual Precipitation A=114 10-25 <br /> On-Site Wetl(s) Yes No Number i Type Irr Dom Pub <br /> S Score S Score S Score <br /> Distance to Wells) from Tank t�ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R condition R condition R condition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet) -l4 f 3 >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) f O None Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of teachate (i.e., septic systems, water wells, ponds) None Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> xxxxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> '?A �) _ J B T X E 8 IT X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 i. 1. NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> e�TPH MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> !_Z. DIESEL 10,000 1000 100 <br /> FOOTNOTES: ***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 If precipitation is > 40 inches, score 0 points. <br /> \3 levels for BTX&E are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION ' <br /> 1. Are BTX b E or TPN Concentrations > Allowable Levels *Yes No <br /> 2. Recommend Site Closure Yes No *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 YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES 110 <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />