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SAN JOAIXi14,00�..+TY PUBLIC NEAUN SER1710ES/ENVIRONMENTAL 416,d.i DIVISION ATE �J 71 <br /> I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> OF FACILITY N N scko� EPS CODE /5-78- <br /> SS <br /> rANK 10 ! � �S 7� <br /> 0o N <br /> PAWAKStzE L TYPE17Se1 <br /> if. GENERAL SITE HISTORY as <br /> s permit current? a o ermit B - scillty Status Code s S oc.Soil/Gw Cont es o <br /> of Tanks at facility ge of Tanks(if available) 1 / 3 ype of Tank teal brgl 1 'Owl <br /> 9 <br /> Ill. TANK HISTORY <br /> s Tsnk tested? es o sited precision test T es o f/ If yes, give dates) <br /> Jaa a repair made to the tank system? es No f yes, what was repaired? <br /> s repair done under inspection? es o ere soil samples analyzed? ea I o TXE PH-G PN-D /ED8 <br /> ype of failure/discharge atsstrophic ang-term leakage erfiti cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> it Samples Received es o th to Ground Water ys of/Year S verNo Annual Precipitation = 4 0-25 <br /> Site wetl(s) es o �umborL Type 1rr am <br /> S Score S Score S core <br /> istance to Welts) from T ft; ft;• ft C 10 pts C 9 pts C pts <br /> '554�z&Zieft4w ZEE O if 0 if O f <br /> R condition R condition R ondition <br /> f. Site Feature - leaching Poten al Analysis eOe' / Oemy, E i s met E is met E s met <br /> inimas Depth to groundwater from the Soft Sanple (feet) 3A' >100 1-100 25-5011 <br /> rectures in subsurface (applies to foothills or mountain areas) None q Unknown resent <br /> verage Arrxnt Precipitation (inches) KXXXXX <10 .9 10-25 Kxxxxxx 26-401,? <br /> 4on-Made conduits which increase vertical migration <br /> f leadute (i.e., septic systems, water wells, ponds) None 9 Unknown Present <br /> ique site features: Recharge area, coarse soil, nearby welts. At least 4ore then <br /> xxxx NOW one one <br /> COLUMN TOTALS»>TOTAL POINTS + 27 + <br /> Samplie Result: (8 T X OR E) RANGE OF TOTAL POINTS9 pts or more 41 48 pts 40 pts or less <br /> N f/w BT X E 8 T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA_U <br /> Sample Result; -jr SOLINE 1000 100 10 <br /> IMUM ALLOWABLE TPN LEVELS (PPM) <br /> ta!LTPN-D IESEL 10,000 1000 100 <br /> FOOTNOTES: •calf 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 soil 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 /> If precipitation is > 40 inches, score 0 points. <br /> Lewis for BTX&E are not appticebte at a TAH concentration of 10 ppm (gasoline) or 100 ppm (diem). <br /> V1. STAFF RECO NEIOATION/CONCLUSION <br /> 1. Are BTX i E or TPN Concentrations > Alloweble levels Yes o e <br /> 2. Recoemand Site Closure es "/ If Yes, Refer to Site Mitigation for Evaluation INT& ON -,;Dos, IQ� <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> rWITH STAFF.RECOMMENDATIOiN FOR CLOSURE ES EFERRED TO SITE MITIGATION FOR EVALUATION S <br /> FERRED / / ATE CLOSURE LETTER MAILEDOR <br /> EN 23 80 (UGTWKSNT)\5/90/ <br /> a <br />