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r <br /> 'N <br /> SAH JOAOI. CCUNTY PUBLIC HEALTH SERVICESIENVIRONMENTA! tiLTN DIVISION /� <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE 7'ry����5F <br /> O <br /> 1 �,y. �� 1 EEPS CODE <br /> E OF FACILITY -5 ! Q �Ii/ ANK 10 0 <br /> DRESS ) ��• <br /> AHK S12E C) UEL u <br /> TYPE QSi9J! 4L4 010 <br /> It. GENERAL SITE HISTORY •s <br /> ermit 9 - acility Status Coda oc.SoiI/GW Cont es o <br /> [s permit eurrent7 es o Oual <br /> uribcr of Tanks at feciEity <br /> ge of Tanks(if available) ype,of Tank te*? brgl n9l <br /> III. TANK HISTORY <br /> Jas Tank tested7 es a ailed precislon test 7 es a If yes, Siva daces) a7/.Z�+/��: L <br /> as a repair made to the tank system? es No f yes, what wan repaired? re le[{ <br /> as repair done under inspection? ea 40 ere sail sanples analyzed? es o TX E PH-G PH-D b/EDB <br /> ype of failure/discharge atestrophie long-term leakafle veH ill sown then: <br /> IV. REMOVAL HISTORY (ATTACH INSP CTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received as o cpth to Ground Water �/�r <br /> of/Year verage Annual Precipitation - 4 0-25 <br /> Site Wells) as o usrber !6 Type lrr om ub S core 5 core <br /> S care <br /> C 0 pts C pts C 5 pts <br /> istance to Well(s) from Tann Jt; ft; ft 0 if o if 0 if <br /> R ondition R condition R ondition <br /> E is met E is met E s met <br /> Site Feature - Leaching Potential Analysis ) 1-100 25.50E <br /> inimum Depth to groundwater from the Soil Sampte (feet) _L�(J ! 100 <br /> restores in subsurface (app((es to foothills or mountain areas) <br /> O Hone Unknown resent <br /> xxxx <t0 9 10-25 26.402 <br /> verage Annual Precipitation (inches) <br /> xxxxxx <br /> an-Made conduits shich increase vertical migration Hone Unknown resent <br /> f leachate (i.e., septic systems, water welts, ponds) ore than <br /> At least <br /> niq.+e site features: Recharge area, coarse soil, nearby wells. xxxx Nona one one <br /> COLUMN TOTALS»)TOTAL POINTS <br /> 41 - 48 pts 40 pts or less <br /> artple Result: (a T % OR E) <br /> RANGE OF TOTAL POINTS 9 pts or more <br /> a T X E a T X E <br /> MAXIMUM ALLOWABLE B-?-X-E LEVELS (PPM) 7 50 50 50 .3 .3 ). 1• HAL <br /> ASOL[HE 1000 100 i0 <br /> ampte Result: <br /> IMUM ALLOWABLE IPM LEVELS (PPM) IESEL 10,00 11(1 1000 100 <br /> TPH <br /> OOTNOTES: <br /> =••lf documented soil and/or groand water contamination is present, do not caiplete the leaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground water. <br /> at ;f depth is > 5 ft. and < 25 ft., score 0 points. It depth -5 5 ft., do not use table. <br /> 1f precipitation is > 40 inches, scare 0 points. <br /> a2 <br /> L Levels for PTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOWtENDATION/CONCLUSION <br /> 1. Are BTX S E or TPA Concentrations >Altowau a Levels (es to <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> V1i. RfVIEV EVALUATICH TO BE COMPLETED BY A SUPERVISOR/SEN <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO S[1E MITIGATION FOR EYALUATI(W ES O <br /> MM <br /> WE REFERRED 1 / <br /> ATE CLOSURE LETTER Ill / <br /> AHE OF <br /> VALUATOR <br /> EH 23 BO (UGTWXSIIT)15/90 <br />