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OUIN"Uk- PUBLIC HEALTH SERVICES/ENVIRONMENTAL 4 ,�IISIONSAN JOADA l �j <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION �+ <br /> I' SWEEPS CODE <br /> NAME OF FACILITY f C <br /> TANK ID # <br /> ADDRESS _� ��f� �/� <br /> FUEL TYPE �( LX�C(�'zd, <br /> TANK SIZE I Q <br /> II. GENERAL SITE HISTORY <br /> Is permit current? Yes No Permit # <br /> Facility status Code Doc.SoiL/GW Cant Yes No <br /> Number of Tanks at facility <br /> Age of Tanks(if available) Type of Tank Steel Fngl Dual <br /> brgi S <br /> III. TANK HISTORY <br /> Yes No Failed precision test ? Yes No if yes, give <br /> dates) <br /> Was Tank tested? <br /> Yes N <br /> Was a repair made to the tank system? o if yes, what was repaired? <br /> Was repair done under inspection? Yes NoI Were soil samples analyzed? Yes No BTXE TP -G ITPH-0' Pb/EDB <br /> 'Type of failure/discharge catastrophic long-term Leakage <br /> overfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Average Annual PrecipitationA= 14 10-25 <br /> Soil Samples Received]Yes '� No Depth to Ground Water Ref/Year ; <br /> � <br /> jon-Site WeLL(S) Yes No Number & Type Irr Dom Pub S Score S Score S Score <br /> ft C 10 pts C 9 pts C 5 pts <br /> Distance to WeLL(s) from Tank ft; ft; if 0 if 0 if <br /> 0 <br /> R condition R condition R condition <br /> E is met E is met E is met <br /> V. Site Feature - Leaching Potential Analysis 25-50\1 <br /> t/� '100 51-100 <br /> Minimum Depth to groundwater from the Soil Sample (feet) L� - 7 <br /> f J-, None Unknown Present <br /> Fractures in subsurface (applies to foothills or mountain areas) I v <br /> xxxxxx <10 9 10-25 xxxxxxx26-40\2 <br /> Average Annual Precipitation (inches) <br /> l <br /> IMan-Made conduits which increase vertical migration None Unknown Present <br /> �of leachate (i.e., septic systems, water wells, ponds) At least More than <br /> Unique site features: Recharge area, coarse <br /> it, nearby wells. one one <br /> xxxxxx None <br /> COLUMN TOTALS»'TOTAL POINTS <br /> 40 is or less <br /> j5ample Result (B T X OR E) RANGE OF TOTAL ?HINTS 49 pts or more 41 48 pts P <br /> B T X E T X I E <br /> NA\3 <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. <br /> GASOLINE 1000 <br /> 100 10 <br /> Sample Result: <br /> MAXIMUM ALLOWABLE TPN LEVELS (PPM) DIESEL 10,000 1040 100 <br /> TPH <br /> ***If documented soil and/or ground water contamination is present, do not complete the leaching potential <br /> FOOTNOTES: <br /> analysis. (i.e., site is currently o^i�ts.Ciftde�tht<=5 ft., darnot�usertable� water. <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 Po P <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for 8TX&E are not appLicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel)_ <br /> vin2a <br /> STAFF RECOMMENDATION/CONCLUSION <br /> & E or TPN Concentrations > Allowable Levels *Yes �( No y( <br /> d Site Closure Yes No <br /> *[f Yes, Refer to Site <br /> Mitigation for EvaLuation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR W17H STAFF RECOMMENDATION FOR CLOSUREIYES� INO (REFERRED TO SITE MITIGATION FOR EVALUATIONIYESI INO <br /> DATE REFERRED / / <br /> DATE CLOSURE L€TIER <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />