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I. SAN I0AiTY PUBLIC HEALTH SERVICES/ENV[RONMENTA!* <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION LTH DIVISION <br /> NAME OF FACILITY DATE <br /> ADDRESS SWEEPS CODE <br /> TANK SIZE FUEL TYPE TANK ID # <br /> It. GENERAL SITE HISTORY <br /> [s Permit current? Yes No Permit # <br /> Number of Tanks at facility Facility Status Code D°C.S°7L/GW Cont yes No <br /> Age of Tanks(if available) Type of Tank Steel FbrgL Si Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test ? Yes <br /> No <br /> Was a repair made to the tank system? Yes if yeS• give dates) <br /> No If yes, what wwaas If <br /> iWas repair done under inspection? Yes No Were soil samples analyzed? Yes <br /> a No BTXE TPN-G Ti Pb/EDB <br /> Type of failure/dischar <br /> 9 catastrophic long-term Leakage <br /> IV. unknown other: <br /> REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA Overfil(FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Ground Water <br /> On-Site WeIL(s) Yes ype Irr pub Ref/Year <br /> NO Number & Dom Average Annual Precipitation A= 14 10-25 <br /> 7 <br /> Distance to Walt(s) from Tank <br /> ft; iiiiiiiiiiiiiiiiiiiiiiiiiiiiii.f 5 Score S Score g <br /> C 10 pts C 9 pts C Score <br /> V. Site Featur0 if 0 if 5 pts <br /> e <br /> Leaching Potential Analysis R condition 0 if <br /> R condition R <br /> Minimum Depth to E is met E is met condition <br /> P groundwater from the Soil SampleE is met <br /> (feet) <br /> Fractures in subsurface (applies to foot )700hills or mountain areas) 51-100 125-501111 <br /> Average Annual Precipitation (inches) None Unknown <br /> (Present <br /> Man-Made conduits which increase vertical migration xxxxxx (10 9 10-25 xxxxxxx 26-40\2 <br /> of Leachate (i.e., septic systems, water wells, ponds) <br /> Unique site features: g y wells. None Unknown <br /> Bechar a area, coarse sail, nearby Present <br /> xxxxxx None At least More than <br /> one one <br /> COLUMN TOTALS>>>TOTAL POINTS <br /> + + <br /> Sample Result: (B T % OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48is <br /> P 40 pts or less <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (Ppm) 19 <br /> 50 50 508 T X E <br /> Sample Result: .3 .3 1. 1. NA\3 <br /> TPH <br /> MAXIMUM ALLOWABLE TPH LEVELS (ppm) GASOLINE 1000 100 <br /> 10 <br /> DIESEL 70,000 1000 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the teaching100 <br /> anal sis. (i.e., site is currentL on UGT Contamination List for soil or Potential <br /> Y <br /> \1 If depth is > 5 ft. and ( 25 ft., score 0 points. If depth <=5 ft., do not use table water.) <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 7. Are BTX & E or TPH Concentrations > Allowable Levels *Yes <br /> No <br /> 2. Recommend Site Closure Yes No if Yes, Refer to Site Mitigation for Evaluation <br /> Vl t. 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 NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF / / <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />