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SAN d0AOUIN Cf PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALOVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> nME OF FACILITY `n"T-J EEPS CCOE 3 QS <br /> )DRESS �J�a/ ///� �.. /` [TANK ID N 3q- ori _Q <br /> TANK SIZE /j 00 o i TYPE <br /> I1. GENERAL SITE HISTORY <br /> Is permit current? es o acitity Status Code 9 oc.Soil/GW Cant aso <br /> umber of Tanks at facility ge of Tanks(ff available) ype of Tank [eel Fbrg( rgl PD,, <br /> Ill. TANK HISTORY <br /> 1as Tank tested? es o ailed precision test 1 es o If yes, give dates) <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> as repair done under inspection? es o ere soft samples analyzed? es o TXE PH-G PH-D b/EDB <br /> Type of failure/discharge atastrophfc long-term leakage verfill nkmm� ther: <br /> IV, REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soft Samples Received ITas o epth to Ground Water ,16 It of/Year ; verage Annual Precipitation k= 4 110-25 <br /> -Site Wetl(s) es o umber 8 Type Irr as ub <br /> S Score S core S core <br /> istance to Wetl(s) from Tank ft; ft; ft C 0 pts C pts C pts <br /> 0 f D if 0 f <br /> R onditim R onditim R ondi tion <br /> Site Feature - Leaching Potential Analysis E is met E is met E 's met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) InNone Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 xxxxxxx 26.40\2 <br /> an-Made conduits which increase vertical migration <br /> if leachate (i.e., septic systems, water wells, ponds) None unknown resent <br /> pique site features: Recharge area, coarse soft, nearby wells. At least lore than <br /> xxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS , O ♦ l g • 10 3 l( <br /> ample Result: (B T X OR E,)p RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> ��l <br /> -1 ' B' 1 qr,m 0 T X E B T X E <br /> / ,� MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1, 1. NA <br /> ample Result: AXASOLINE 1000 100 10 <br /> INUN ALLOWABLE TPN LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> OOTNOTES: "•lf 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 soft 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 BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF REC"ENOATION/CONCLUSION -'T S X.0/ } <br /> O� �in B ^ ID <br /> 1. Are BTX $ E or TPN Concentrations > Allow to Levels Yes o P t p j � ,� r' c k <br /> k, <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Hiti ga[ion for Evaluation ©, <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE NfiICATION FOR EVALUATION. ES O <br /> ATE REFERRED / ATE CLOSURE LETTER MAILED ¢ j <br /> InnEOF <br /> :VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />