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SAN 1OACUI1 COUN*LIC HEALTH SERVICES/ENVIRONMENTAL HEALTH SION <br /> UG KSHEET FCR SITE CLOSURE EVALUATION <br /> NAME OF FACILITY CG2-1 (/� -79' SWEEPS CODE f � <br /> ADDRESS 3 5-0- , . ei,; s7 /0 G TANK ID T� <br /> TANK SIZE /C�.GyUU F EL TYPE SN 9r.L cz� c ' E7 <br /> I1. GENERAL SITE HISTORY <br /> 1.; permit current? Yes y' No Permit # - Facility Status Code Doc.Soit/GW ContlYes No <br /> Nurbcr of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgt SngL Dual <br /> iii, TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test 7 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 TPH-G TRH-D Pb/EDG <br /> Type of failure/discharge catastrophic long-term teakage overfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes Nol Depth to Ground Mater Ref/Year Average Arcual Precipitation A= 14 10-25 <br /> Or.-Site WeLt(s) YesNo Number & Type Irr Dan Pub <br /> S Score S Score s Score <br /> Distance to WeLL(s) from Tank 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. SiCe Feature - Leaching Potential Analysis E is met E is met E is met <br /> Mirimun Depth to groundwater from the Soil Sample (feet) X100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) 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 leachate (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 /> 8 TX E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1, 1. NA\3 <br /> Sampte Result: GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH DIESEL 10,001) 1000 100 <br /> FOCTNOTES: ***If documented soft 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 snit 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 TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VT. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No <br /> 2. Recommend Site Closure Yes No If Yes, Refer to Site Mitigation for Evaluation <br /> VIS. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CCNU-,R WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION TES NO <br /> DATE REFERREDI DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUAIOR <br /> EH 23 30 (UGTWKSHT)\5/90 <br />