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!• SANN <br /> d i p COUN'Y <br /> PUBLIC HEALTH SERVICES/ENVIRONMEh <br /> AMI; OF UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> FACILITY HEALTH DIVISION <br /> DRESS ATE <br /> � WEEPS CODE <br /> ANK SIZE e s <br /> UEL TYPE <br /> ii. GENERAL SITE HISTORY <br /> Is permit current7 es <br /> o ermit # <br /> Umber of Tanks at facility acilfty Status Code <br /> _ ge of Tanks(if 5o Gll Cont es ° <br /> TANK HISTORY available) tet//g. Ype of Tank Leel oc( brgl , <br /> ngt uat <br /> as Tank tested? es <br /> ° .ailed preci <br /> as a repairsion test 1 es ;.: <br /> o If yes, give dates) <br /> made to the tank system? es No <br /> es, what was repaired? <br /> as repair done under ins <br /> pectian7 es o ere soil samples analyzed? es <br /> ype of failure/discharge atastro fc ° TX H.G H'D b/EDB <br /> Ph long-term leakage verfitl known <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> . oil Samples Received es <br /> o e th to Ground Water Sb of/Year rr <br /> -Site Wetl(s) es ° umber 8 Type Irr f b verage Amual Precipitation = 4 0-25 } <br /> an ub <br /> istance to Wett(s) from Tank S core S care <br /> ft C 0 is S core <br /> 0 if p C pts C pts <br /> 0 if 0 f <br /> Site Feature <br /> Leaching Potential Analysis R ondition R ondition R <br /> E is met E is met on <br /> dit <br /> inimra<,n Depth to groundwater frarn the Soi l Sarrple (feet)5-0— �o S� - >700 E smet <br /> -s mer <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown resent 1 100 25 501 <br /> verage Annual Precipitation (inches) ' <br /> an-Made conduits which increase vertical migration xxxx 00 9 10-25 xxxxxx 26-40_2 <br /> f leachate (i.e., septic systems, grater wells, ponds) I` <br /> l-C> Hone Unknown resent• <br /> nique site features: Recharge area, coarse soil, nearby wells. <br /> At least ore than <br /> xxxx None one <br /> one <br /> COLUMN TOTALS»>TOTAL POINTS I <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9is or more <br /> p 41 - 48 pts 40 pts or Less <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1, <br /> ample Result: NAi <br /> iPH <br /> IMIM ALLOWABLE TPH LEVELS (PPM) ASOLINE 1000 1oO ' 10 <br /> � r <br /> IESEL 10,000 iDOD 1Q, <br /> 00T40TES: *"If documented soil and/or ground water contamination is present, do not carp e e the leachinQ potential a <br /> analysis. (i.e., site is currently on UGT Contnmfnatlan List far sell Ir grcjr,d water.) <br /> ]1 If depth is > 5 ft. and < 2S ft., sF13ee D' Pc'nls. Ifc_ <br /> 11 T�ipitation is > 40 inches score D t1! 'r ft., do not use table. i <br /> 13 Levels for BTX&E are not applicable at a points. <br /> Hnconcentration of 10 <br /> ppm (gasoline) or 100 ppm (diose!). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPR Concentrations > Allowable Levels Yes , <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES O EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> i, <br /> EN 23 80 (UGTWKSHT)\5/90 <br />