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n <br /> SAN .i.y Jt" '"OUNTY PUBLIC HEALTH SERVICES/EHVIRONMEh"ixti 'LTH DIVISION <br /> I. UGST WORKSHEET FOR SITE CLOSURE EVALUATiO409* IiATE <br /> AME OF FACILITY WEEPS CODE s I <br /> DRESS �S ANK ID <br /> ANK SIZE UEL TYPE <br /> E <br /> 11. GENERAL SITE HISTORY <br /> ** <br /> Is permit current? es o f 4ermit tl - acility Status Code oc.Soil/GW Cont es o <br />€" umber of Tanks at facility BP of Tanks(if available) N/A ype of Tank teel brgL , ngl Wal <br /> i <br /> 111, TANK HISTORY <br /> Jas Tank tested? eso ailed precision test ? es o If yes, give date(s) <br /> as a repair made to the tank system? Yes Noes, what was repaired? <br /> Jas repair done under inspection? es o ere soil samples analyzed? es o )T% PH-G PH-D b/ED8 <br /> I� <br />} ype of failure/discharge atastrophlc tong-term leakage verfill Hawn they: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTI"REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es I j,+I e th to Ground Water Sb' of/Tear 6 verage Annual Precipitation <br /> 3n-SteiWells) es o umber & Type Irr om ub <br /> S Score 5 Score S core <br /> istance to Wet{(s) from Tank -f t; ft; ft C 10 pts C9 pts. C pts <br /> 0 if 0 if 0 f <br /> R condition R condition R ondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E s met <br /> inimun Depth to groundwater from the Soil Sample (feet) / >100 1-100 25-50L <br /> ractures in subsurface (applies to foothills or mountain areas) v None Unknown resent <br /> verage Annual Precipitation (inches) xxxx <10 9 10-25 KXXXxxx 26-40L2 <br /> an-Made conduits which Increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) /0 None Unknown resent, <br /> -- Fq <br /> pique site features: Recharge area, coarse soil, nearby wells. At least ore than <br /> xxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS 20 + + �3 <br /> ample Result: (B T % OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> p 13 m B TLq <br /> 'BT XMA%IMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 5 .3 .3 1. 1. NAL <br /> Sample Result: SOLINE 1000 100" 10 <br /> IMUM ALLOWABLE TPN LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> OOTNOTES: ***If documented soil and/or ground water contamination isresent do not c ng potential <br /> A omplete the leaching <br /> analysis. (i.e., site is currently on UGT Contamination List for soil orground water.) <br /> 1 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 /> ,L3 Levels for BTUE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diene{). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1, Are BTX & E or TPN Concentrations > Allowable Levels Yes o <br /> 2, Recommend Site Closure es a If Yes, Refer to Site Mitigation for Evaluation <br /> V11. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALON ES <br /> UATIO <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> -VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 i <br /> t <br />