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1. SAN JL, Jk NTY PUBLIC HEALTH SERVICES/ENVIRONMEaIAL TH DIVISION <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> _/ r <br /> AME OF FACILITY <br /> DRESS WEEPS CODE <br /> S <br /> 7 AHK ID N <br /> ANK SIZE <br /> SS LIEL TYPE <br /> Ii. GENERAL SITE HIS ORY <br /> Is permit current? as o ermit * - acility Status Code ** <br /> f oC.Soil/GW Cont es o <br /> umber of Tanks at facility _ ge of Tanks(if available) <br /> of lank teal brgl ngl ual ,� <br /> 11t. TANK HISTORY <br /> h , as Tank tested? es o ailed precision test 7 es <br /> o If yes, give date(s) <br /> as a repair made to the tank system? es No is, what was repaired? <br /> as repair done under ins <br /> peccian7 es o ere sol! samples analyzed, <br /> es o TX PH-G PH-D b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfill known then; <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION SPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received as o e th to Ground Waterof/Year <br /> � � � veraga Arcual Precipitation ka 4 0-25 <br /> Site Vett(s) es a umber 8 Type Irr an ub <br /> istance to Welts) from TankS core S Score S core <br /> ft; ft; ft C 0 pts C 7 pts C pts <br /> O if O if O f <br /> V. Site Feature - Leaching Potential Analysis R ondriron R axiition R ordition <br /> E is met E is met E 5—mer <br /> inimum Depth to groundwater from the Soil Sample (feet) .�-� �_ >100 1-100 25-54L1 <br /> ractures in subsurface (applies to foothills or mountain areas) None unknown re <br /> verage Arcual Precipitation (inches) -LXXXX <10 9 10-25 xxxx 2b-40L <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) l C7 None Unknown resent, <br /> pique site features: Recharge area, coarse soil, nearby wells. At least 4ore than <br /> xxxx None one one <br /> COLUMN TOTALS—TOTAL POINTS + l!Y t S V-3 <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 4Bor is is 40 <br /> P p less <br /> ND B T x E B T x E <br /> MAXIMUM ALLOWABLE B-T X-E LEVELS (PPM) 1 50 50 50 .3 .3 x 1. NA13 <br /> ample Result: ASOLINE 1000 100 10 <br /> 3 OCA IMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> OOTHOTES: ***If documented soil and/or ground water contamination is present, do omplete a leaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for sat or ground water.) <br /> L if depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> If precipitation is > 40 inches, score 0 points. <br /> J3Levels for BTX8E are not applicabte at a TPH concent tion of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOM ENDATION/CONCLUSION I` <br /> 1. Are BTX & E o TPH oncentrations > Allow le Levels Yes o r r <br /> 2. Recommend Site Closure ea o 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 i YESI0 EFERRED TO SITE MITIGATION FOR,E VALUATION E5 11' O i <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> TAME OF <br /> "VAWATOR <br /> i <br /> EH 23 80 (UGTWKSHT)15/90 <br />