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SAN JOADU.J& ) <br /> NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H DIVISION DATE "1 <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION -T - <br /> NAME OF =AGILITY 1� (SWEEPS CCOEj <br /> v <br /> `7�SANK ID <br /> i ADDRESS r <br /> !TANK SIZE1 �)�i� (FUEL TYPE! 2 <br /> II. GENERAL SITE~HISTORY <br /> r.+ <br /> is permit current?IYes I No Permit mI - (Facility Status Cocel rylDoc.Soil/GW Cont�Yes No <br /> INumcer of Tanks at facility <br /> Age of Tanks(if available)( hype of Tank Steel Fbrgl ISngl1 Dual <br /> III. TANK HISTORY <br /> Lil <br /> Was Tank tested? Yes INoI (Failed precision test ?lYesl INoI lIf yes, give cate(s) <br /> Was a repair made to the tank system?IYesl mol IIf yes, what was repaired?) <br /> Iuas repair done under inspection?,Yes, INoI Were soil samples analyzed?lYesl INoI STXEI (TPH-GI I TPH-DI IPb/EOBI <br /> Type of failure/discharge) catastrophic (long-term leakage) Ioverill Iunknown) )other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> i <br /> Soil Samples Received Yesl NoI (Depth to Ground Water (Ref/Year) (Average Annual PrecipitationlA= 14 10-25 <br /> ion-Site Well(s) Yes) INoI (Number 8 type) IIrrl IDoml IPI S Scare S Score S (Score <br /> Distance to Well(s) from Tankl ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if O if 0 if <br /> R condition R condition R condition <br /> jV. Site Feature - Leaching Potential Analysis _ is met = is met c is met <br /> Minimum Depth to groundwater from the Soil Sample (feet),,20-0 = l l >100 I I51-100 i I 5-50\1 <br /> ;Fractures in subsurface (applies to foothills or mountain areas) II I None I I Unknown I jPresent <br /> ;Average Annual Precipitation (inches) (xxxxxxl <10 I 9 110-25 Ixxxxxxxl 26-40\2 <br /> IMan-Mace conduits which increase vertical migration I l I None I Unknown I (Present <br /> !of Leacnate (i.e., septic system;, water wells, ponds) t) <br /> (Unique site features: Recharge area, coarse soil, nearby wells. i I f At least) (More than one <br /> XXXXXX None one <br /> I <br /> 14k0 (.Y.'m re . lo yn <br /> 1 COLUMN TOTALS—TOTAL POINTS l ( + <br /> ISamale Result- (B T X OR E) RANGEOF TOTAL POINTS149 pts or more I 41 - 48 pts L 40 pts or less <br /> Ir�''YP��' B T X I E B T X E <br /> 0 I i- t _ i3 7►�- MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1� 50I 501 50 ! .3 I.3 11.I 1., <br /> I NA\3 <br /> ISamale Result: / e GASOLINE 1000 l 100 10 <br /> j( {✓ = I R 1)O pf m MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> �PH DIESEL 10,000 l 1000 I 100 <br /> FOOTNOTES: * If documented soil and/or ground water contamination is present, do not C fete the leaching-potential <br /> I analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> a t<" -s"•otp1� \1 If death is > 5 ft. and < ZS ft., score 0 points. If depth <-5 ft., do not use table. <br /> t <br /> 0 • \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> I <br /> VI. STAFF RECOMMENDATION/CONCLUSION �J( 1 ��1 T-0 -3 <br /> C l <br /> i stn <br /> 1 1. Are 3TX & E or TPN Concentrations > Allowable Levels *Yes NoI I K ;4,-Q, �-,�{� <br /> _ C. <br /> 2. Recommend Site ClosurelYesl No E*If Yes, Refer to Site Mitigation for Evaluation <br /> L3 3 �"tj Ali N� <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSUREIYESI -jNOI IREFERRED TO SITE MITIGATION FOR EVALUATIONIYES r- NO) <br /> DATE REFERRQ �� IDA7E CLOSURE LETTER MAILED( <br /> NAME OF <br /> EVALUATOR 1 <br /> EH 23 80 (UGTWKSHT)\5/90 <br />