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I, SAN A"dUOUNTY PUBLIC HEALTH SERVICES/ENVIRONMENT f- <br /> LTH DIVISION <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> AME OF FACILITY ATE <br /> DRESS P WEEPS CODE <br /> "s I <br /> ANK S17E �QO ! TYPE AHK ID (1 3c�- gyp- (� <br /> I1. GENERAL SITE HISTORY <br /> Is permit current? es o rmit ar ** <br /> scility Status Code oc.Soil/GW Cont es o , <br /> umber of Tanks at facility _ ge of 7anks(if available) j <br /> ype of Tank Leel brgl , ngl ual <br /> 1I1. TANK HISTORY <br /> as Tank tested? es o ailed precision test 7 as <br /> a If yes, give date{s} <br /> as a repair made to the tank system? as No es, what was repaired7 <br /> as repair done under inspection? as 40 ere soil samples analyxed7 es o ITX PH-G PH-0b/EDB <br /> YPe of faiture/dischar e <br /> g atastrophic Fong-term leakage verfill <br /> nknown the <br /> r. <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPbRT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received as o e th to Ground Water � of/Year f verage Annual Precipitation = 4 0-25 <br /> Site Wells} es o umber & Type Irr om ub <br /> S core S core S core <br /> istance to Wells) from Tank ft; ft; ft C 0 pts C pts C is <br /> O if o if R fP <br /> R onditian R audition R orYl{tion <br /> Site Feature - Leaching Potential An E is met E is met E s met k <br /> inimum Depth to groundwater from the Soil Sample (feet) �v '�a2 >100 1-100 s 25-501 <br /> ractures in subsurface (applies to foothitts or mountain areas) None Unknown resent F <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 Kxxxxxx 26-40i <br /> 3 <br /> an-Made conduits which increase vertical migration <br /> Df leachate (i.e., septic systems, water wells, ponds) None Unknown resent- <br /> pique site features: Recharge area, oarse sol , nearby wells. At (ease 4ore than <br /> xxxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS c_-{J + <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS F9 pts dr more 41 - 48'pts 40 pts or less <br /> V BT X E B T E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 11. HA <br /> . L <br /> ample Resutt: SOLINE 1000 .w 100 10 <br /> IMM ALLOWABLE TPH LEVELS (PPM) <br /> TPH C-5- IESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented sail and/or groundwater contamination is present, do not to the teaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> i if depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> ,L2 if precipitation is > 40 inches, score 0 points. <br /> ,L3 Levels for BTXBE are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 pian (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION r I. <br /> tv¢ } <br /> 1. Are BTX & E or TPH Concentrations evel <br /> Allowable Ls Yes o l <br /> 2. Recommend Site Ctosure es o If Yes, Refer to Site Mitigation for Evaluation L" f <br /> VII. REVIEW EVALUATION - TO BE COMPLETED-BY A SUPERVISOR/SENIOR i <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE fESOVJ <br /> EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / r C--/ ATE CLOSURE LETTER WAILED <br /> AME OF <br /> =VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />