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SAH J. COUNTY <br /> PUBLIC HEALTH SERSITE <br /> CLOSURE <br /> VIRONMEN7 <br /> AME OF FACILITY UST WORKSHEET F <br /> OR SITE CLOSURE EVACUATION 'H D!V'cPON <br /> GDRESS ��'�' w � <br /> - RTE <br /> ARK SIZE ��~ J ECORD ID / J <br /> `rV FU L TYPE ' / <br /> 1I. GENERAL SITE HISTORY ANK ID # <br /> 0 c� <br /> Is permit current? es <br /> ° ermit # <br /> umber of Tanks at facility - <br /> acitity Status Code Q <br /> ge of i °c.Soil ** <br /> 11l. TANK HISTORY Tank(if available) /GW Cont <br /> es o <br /> as rank rested? <br /> YPe of Tank teet Fbrgl <br /> es <br /> ° ailngl Dual <br /> ed precision test ? <br /> as a repair made to the tank s es <br /> ° If yes, give date{s) / <br /> system? es No f yes what <br /> as repair done under ins <br /> pection? es was repaired? / <br /> Ype of failure/discharge ° ere soil samples analyzed? es <br /> atastr°phiC ° TXE <br /> IV. REMOVAL HISTORY long-term leakage PH-G PH'D <br /> (ATTACH INSPECTION verfill nknown b/EDB <br /> Oil Samples REPORT FoR SITE DETAILS/COLLECT DATA F Cher: <br /> p Received es DR LEACHING <br /> ° epth to Ground Water / POTENTIAL ANALYSIS} <br /> n-Site We(((,) Od of/Year �C.• <br /> es o Umber & T <br /> % 3 verage Annual Precipitation = 4 0-25 <br /> isranee to WeII(s) from Tank Type Err cm ub <br /> -��ft; S <br /> ftC core S <br /> 0 pts core S <br /> Site Feature - Leaching0 C pts Core <br /> Potential A �f 0 C _ pts <br /> inimum Depth to Analysis R ondition if O <br /> groundwater fromE R ondition f <br /> the Soil �s met E R ondition <br /> ractures in subsurface (a Sample (feet) �s met E <br /> `s met <br /> (applies to foothi41S or mo >100 1-100 <br /> verage Annual Precipitation i mountain areas) � 25-50� <br /> (inches) None Unknown <br /> an-Made conduits which increase vertical xxxxx <iQ resent <br /> f leachate (i.e 9 10-25 <br /> septic systems migration xxxxxx 26-40L2 <br /> water wells, ponds) <br /> nique site features: Recharge area, c <br /> CMuncipat=>2000 ft• None Unknown <br /> domestic=>500 ft; ir°r�ae soul, or welts. <br /> resent <br /> gricultural=present) <br /> xxxx None At least <br /> COLUMN TOTALS»> one <br /> ore than <br /> TO7AL POINTS one <br /> ample Result: (g T X OR E) Z7 <br /> RANGE OF TOTAL POINTS + -3 Z <br /> _� 9 pts or more 41 <br /> - 48 pts 40 pts or fess <br /> 1 5 <br /> MAXIMUM ALLOWABLE 8-T-X-E LEVELS (PPM) 0 50 50 <br /> ample Result: ® T X E B T X E <br /> 3 J <br /> 1. 1. NAL3 <br /> TPH <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) ASOLlNE 100Q <br /> 100 <br /> OOTNOTES: *** IESEL 10 <br /> [f documented 10'000 1Q00 <br /> soil and/or ground water c 100 <br /> analysis. (i Or <br /> site is currently on <br /> fs <br /> L1 If depth is > 5 ft- Y n UGT C present, do not complete the (each i <br /> 1 If precipitation is >yI0cinches score 0 points. Iftdaeptht<on List for soil or ' potential <br /> 1 Levels for score Q 5 ft., ground water,} <br /> B7X&E are notapplicablePoints. � not use table, <br /> STAFF RECOMMENDATION/CCNCLUSION at a TPH concentration of 10 <br /> pP'm (gasoline) or 100 ppm (diesel). <br /> 1• Are BTX & E or TPH Concentrations > <br /> Allowable Levels Yes <br /> Recommend Site Closure es o <br /> ° If Yes <br /> REVIEW EVALUATION - TO BE , Refer to Site Mitigationfor Evaluation <br /> r COMPLETED BY A SUPERVISOR/L SENIOR <br /> 'CUR WITH STAFF RECOMMENDATION FOR CLOSURE ES <br /> REFERRED 0 EFERRED TO SITE MITIGATION FOR EVALUATION <br /> ES 0 t <br /> OF ATE CLOSURE LETTER MAILED <br /> [ATOR <br /> 80 (UGTWKSHT)\5/94 <br />