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fI <br /> I <br /> !. SAN 1�,v� NTY PUBLIC HEALTH SERVICES/ENVIRONMENT-f UTH DIVISION <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> AME OF FACILITY ATE <br /> DRESS WEEPS CODE <br /> ANK SIZE 7 ANK ID # <br /> UEL TYPE f / <br /> 11- GENERAL SITE HISTORY <br /> Is permit current? es o ermit # r <br /> of Tanks( <br /> umber of Tanks at facilityacility Status Code oc-Soil/GW Cont es <br /> � � o <br /> jBe if available) ,V/,g- ype of Tank teal <br /> f fli. TANK HISTORY nBl ual <br /> as Tank tested? es o ailed precision test ? es <br /> 0 If yes, give date(s) / <br /> as a repair made to thetonksystem?tem? es No e <br /> , <br /> what was repaired? <br />` as repair done under inspection? es o <br /> f ere soil samples analyzed? es <br />€ ype of failure/discharge Tx PH-G PH-D b/EDB <br /> atastrophie iortg-term leakage verfill <br /> nown Cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Oil Samples Received es o e th to Ground Water <br /> of/Year � � verage Arcual Precipitation 4 0-P5 <br /> -Site Welt(s) es 0 umber & Type Irr <br /> am ub <br /> istance to Wells) from Tank ft; ft; S core S core S core <br /> C <br /> �ft 0 if pis 0 ifpts C pts <br /> 0 f <br /> Site Feature - Leaching Potential Analysis R °edition R andition R ondition <br /> E is met E is met E s met <br /> inimum Depth to groundwater from the Soil Sarple (feet) <br /> � —/o.s >TDO 1-100 25-5011 <br /> ractures in subsurface (applies to foothills or mountain areas) <br /> /v Hone Unknown resent .1 <br /> verage Arcual Precipitation (inches) f <br /> xxxx 00 91 10-25 xxxx 25-40i <br /> on-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) <br /> I'D None 1° Unknown resent, <br /> nique site features: Recharge area, coarse soil, nearby wells. <br /> At least 40re than <br /> xxxx Hone `� one one <br /> J <br /> COLUMN TOTALS>>>TOTAL POINTS7 + �� <br /> v + �3 <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 4$ pts 40 pts or less !! <br /> X MAXIMUM ALLOWABLE B-T-X-E8 T X 5 .3 .3 X 1. <br /> ample Result: NA.]3 <br /> t{b TPH IMUM ALLOWABLE TPN LEVELS (PPM) ASOLINE 1000 100 10 <br /> IESEL 10,000 1000 100 <br /> OOTHOTES: """If documented soil and/or ground water contamination is present, do no[ c fete the teachi <br /> analysis- (i-e., site is currently on UGT Contamination List for sail or potential <br /> 11 If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. water.) <br /> _\2 If precipitation is > 40 inches, score 0 points. <br /> 13 Levels for BTX&E are not applicable ata TPH concentration of 10 <br /> ppm (gasoline) or 100 ppm (diesel). <br /> VT. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or E <br /> oncentrations > Allow le Levels Yes o <br /> 1 <br /> 2. Reconmend Site re es o If Yes, Refer to Site Mitigation for Evaluation <br /> V11. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> OHCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED 4 <br /> ATE CLOSURE LETTER hAfLED <br /> AME OF 1 <br /> VALUATOR <br /> Eli 23 80 (UGTUKSHT)\5/90 ! <br /> i <br />