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SAN ICAtU]IN TY PUBLIC HEALTH Sc-RVICS/E.NVIRONME.NTAL HFji& OIVISICH <br /> I. ST WORKSHEET FOR SITE CLOSURE _VALUATION IDATE I <br /> NAME OF FACILITY :TAM v l C P, <br /> SWEEPS CODE( <br /> ADORESSI <br /> ( TANK ID -I <br /> TANK SIZEFUEL PE' <br /> 11. C;ENERAL SITE HISTORY <br /> Is permit current? Yes INe (Permit ( - (Facility status Code) IDoc.Soil/GW Conti Yesl INoI <br /> Nuaoer of Yanks at facility Age of 7ankS(if available)( (Type of ranklS:eell IFbrgll ISngtl 0uall <br /> 211. TANK HISTORY <br /> Was Tank tested? Yes No (Failed precision test ?I Yes INoIX If yes, give date(s)I <br /> Was a repair .made to the :ank syscem?I Yes No IIf yes, what was repaired7I <br /> Was repair done under inspection?(Yes INoI IWere sail samples analytec?I Yes INoI BTXEI (TPH-GI I TPN-DI IPb/©BI <br /> Type of failure/discharge) Icatastrophic l hang-term leakage) Ioverfiltl Iunknow l (other. <br /> IV. 2EMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE OEi AILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes INoI (Depth to Ground Water) Ret/yearI (Average Annual Precipitaiionl A=I 14 It0-ZS <br /> On-Site Well(s)I Yesl INoI INuaoer 3 Type IIrrI ID=I IPubl <br /> 5 Score S scare S (Score <br /> Distance to Wetl(s) from tankl ft; ft; ft C to pts C 9 pts 1: <br /> 5 pis <br /> 0 if 0 if D hr <br /> R condition R condition R condition <br /> V. Site Feature - leaching Poiencial Analysis _ is met _ is met E is met <br /> Minimum Oepth to groundwater from the Soil Sample (fee_U 56 — I I >100 l j51-100 I. 25-50\l <br /> i <br /> (Fractures in subsurface (applies to feothitls or mountain areas) I Nave I Unknown I Present i <br /> Average Annual Precipitation Ondhes) 1===l <10 I 9 110-5 lapeoa=j 25-40\2 I <br /> (Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systema, water wells, ponds) Norte Unknoah (Present <br /> Unique site features: Recharge area, coarse soil, nearby welts- I At leestl (More than <br /> :XX= None one one <br /> COLUMN <br /> COLUMN iOTALS>»TGTAL POINTS - = ' / <br /> Sample Result: (9 7 X OR E) RANGE OF TOTAL POINTS 49 pts or more 'l . ?. - 4a Pis 40 Pts or less <br /> 3 T X E 3 7 X <br /> MAXIKJM ALLOWABLE 3-Y-X.E LEVELS (PPM) lI 50 sof 50 .3 .3 1. 1. NA\3 <br /> Sample Result: GASOLINE 1000 Lwc=p <br /> t0 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH DIESEL lo,ow 100 <br /> 'FOOTNOTES: " Tf aocumer:ted soil and/or ground water contamination is presem, do ;3 ;Jamchins Potential <br /> analysis. (i.e., site is currerhtty on UGT Contamination List for soil or grand water.] <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth �5 ft., do not use cable. <br /> \2 If precipitation is > 40 inches, Score 0 points. <br /> \3 Levels for 31'XSE are not applicable at a TPH coneerttratfon of 10 ppm (gasatine) or 100 pan (diesel). <br /> VI. STAFF RECOMMENDATION/CCNCLUSION <br /> 1. Are 3TX 3 E or TPH Concentration > Atlowable Levels I-Yesl INoI <br /> 2. Recommend Site Closure)yell INoI If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO SE COMPLETED BY A SUPERVISOR/SSIOR <br /> CCNCUR WITH STAFF RECCMMENDATICN FOR CLOSURE(YESI INOI IRE=ERR© t0 SITE MITIGATION FOR EVALUAT]CNIYESI HCI <br /> DATE REFERRED( / / (DATE CLOSURE LZ7jR MAILED( <br /> NAME OF <br /> EVALUATORI <br /> EH 23 80 (UGTWKSHT)\5/90 • <br /> • <br />