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1. <br /> ' SAH ". J"'=COUNTY PUBLIC HEALTH SERVICES/ENVIRONM>zktA'l ALTH DIVISION <br /> AME OF FACILITY <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUAT16,.,� <br /> ATE _ r <br /> DRESS WEEPS CODE <br /> cS 92 <br /> AHK SIZE AHK ID i! _?p- /cess <br /> 3 500.-oUEL TYPE she of l 4 <br /> lI. GENERAL SITE HISTORY P <br /> Is permit current? es o ermit tf _ ** <br /> ty Status Code ont <br /> unbar of Tanks at facility _ <br /> ge of Tanks(if available)aciliOC-Soil/GU Ces O N�i9" ype of Tank reel brei , ngl Wal <br /> j Ill. TANK HISTORY <br /> as Tank tested? es <br /> a ailed precision test ? es <br /> 0 1f yes, give date(s) <br /> as a repair made to the tank system? es No <br /> es, what was repaired? <br /> as repair done under inspection? es o <br /> ere soil samp{es analyzed7 es o Tx PH-G PH-D 6/EDB <br /> ype of failure/discharge atastrophic Long-term leakage verfill Hawn 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 /> S-L-) of/Year � G verage Annual Precipitation = 4 0-25 <br /> -Site Wells) es 0 umber 8 Type Irr <br /> om ub i <br /> istance to Uell(s) from TankfCi ft; S core <br /> S core S core f <br /> ft C 0 pts ': O ifpts C pts <br /> i <br /> 0 f <br /> Site Feature - Leaching Potential Analysis R Ondition R ondition R ondition <br /> E is met E is met E s met <br /> inimum Depth to groundwater from the Soil Sarmale (feet) <br /> >100 1-100 <br /> ractures in subsurface (applies to foothills or mountain areas) None <br /> [� i, Unknown resent <br /> verage Annual Precipitation (inches) <br /> xxxx 410 9 10-25 xxxx 25-40,LZ <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) <br /> l 0 Name Unknown resent, <br /> nique site features: Recharge area, coarse soil, nearby wells, <br /> At least ore than <br /> xxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS Z� ; Af t ��? <br /> r <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 1 - 48 pts 40 pts or less F <br /> j 9 8 T X E 8 T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 SO 50 50 ,3 .3 1. 1. NAL <br /> ample Result: <br /> '// ASOLINE 1000 100 10 <br /> `1r S �� IMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH 1000 100 <br /> IESEL 10,000 <br /> { <br /> OOTNOTES: ***If documented soil and/or ground water contamination is present, do romplete the eaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for s ' or water.) <br /> �1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth ­5 ft., do hot use able. <br /> If precipitation is > 40 inches, score 0 points. <br /> ,13 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX d E or TPN Concentrations > ALL wable 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 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES e <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> i <br /> s <br /> t <br />