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rj4AHSAN JOAOUih TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL h,Id,0H DIVISION <br /> E <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> OF FACILITY � WEEPS CODE <br /> ESS TANK ID 0 <br /> TANK SIZE UEL TYPE <br /> Ii. GENERAL SITE HiSTORY <br /> ww <br /> is permit current7 es o ermit # acility Status Code oc.Soil/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) IT ype of Tank teebrgl IS <br /> ngl I Dual <br /> ill. TANK HISTORY <br /> y ,1s Tank tested7 es o IFafled precision test ? es o If yes, give date(97) <br /> as a repair made to the tank system? Yes No 1 11f yes, what was repaired? <br /> ns repair done under inspection? es o ere soil samples analyzed? es to TIE PH-G PH-0 b/EDB <br /> ype of failure/discharge atastrophic long-term leakageverfill nknown cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es o epth to Ground Water of/Year verage Arcual Precipitation 4 10.25 <br /> -Site Well s) es o umber 9 Type Irr om ub <br /> Score S core S core <br /> Istance to Wells) from Tank ft; ft; ft C 0 pts C pts C pts <br /> 0 if 0 if 0 if <br /> Randitfon R condition R ondition <br /> V. Site Feature • Leeching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from!the Soft Semple (feet) >100 1.100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown Present <br /> < 9 10-25 xxxxxx 26-40\2 <br /> average Arcual Precipitation (inches) xxxxx 10 <br /> P <br /> an-Made conduits which increase vertical migration <br /> f teachate (i.e., Septic systems, water wells, ponds) None Unknown Present <br /> Inique site features: Recharge area, coarse soil, nearby wells. At least ore than <br /> xxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS + + <br /> ample Result: (0 T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or less <br /> B I 1 X E e T X E <br /> MAXIMUM ALLOWABLE 0-t•X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> ample Result: ASOLiNE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> FOOTNOTES- ***If documented soil 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 soil or ground water.) <br /> 0 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 OWE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1, Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o 1 ` <br /> r V" <br /> 2. Recommend Site Closure 1Y <br /> es o If Yes, Refer to Site Mitigation for Evaluation 6-�4 0 <br /> Y. <br /> w <br /> ViI. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> :¢ -ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> j <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED 1 / <br /> AME OF <br /> .VALUATOR <br /> EH 23 80 (UGtWKSHT)\5/90 <br /> EH 29 80 <br />