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SAH JC N COUNTY PUBLIC HEALTH SERVICES/ENVIRONMEN °ALTH DIVISION <br /> I• �/ UGST WORKSHEET FOR SITE CLOSURE EVALUAhd )n c <br /> FANKSIZE <br /> OF FACILITY ATE /V—a �✓7 0 <br /> �e WEEPS CODE <br /> d' T ��> <br /> TANK 1D it <br /> - lay -D <br /> /DOL UEL TYPE ` <br /> II. GENERAL SITE HISTORY <br /> 11spermites o ermit it 3 9 - oo ,3 yy acility Status Code oc.Soil/GW Cont es ot facility 0 ge of Tanks(if available) ype of Tank teal Fbrgl ngl Dual <br /> III. TANK HISTORY <br /> as Tank tested? as o ailed precision test 7 es o If yes, give date <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> as repair done under inspection? es o ere soil samples analyzed? es o TXE IPH-G PH-D b/EDB <br /> ype of failure/discharge I atastrophic long-term leakage verfill noun then: <br /> IV. REMOVAL HISTORY (ATTACH INSP MON REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> SOIL Samples Received es o epth to Ground Waterof/ ear <br /> U Y , verage Annual Precipitation - 4 0-25 <br /> -Site Wells) es o umber $ Type Irr om ub <br /> istance to Wells) from Tank ft; 1 S core S core S core <br /> ft ft C 0 pts C pts C pts <br /> 0 if 0 if 0 if <br /> i. Site Feature - Leaching Potential Analysis R ondition R ondition R ondition <br /> E is met E is met E is met <br /> inimun Depth to groundwater from the Soil Sample (feet) ." 3 >100 1-100 <br /> 25-SOL <br /> ractures in subsurface (applies to foothills or mountain areas) <br /> None Unknown resent <br /> veroge Annual Precipitation (inches) xxxx <10 9 10-25 xxxxxx 26-40\2 <br /> an Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) Kane <br /> Unknown � resent <br /> nique site features: Recharge area, coarse soil, nearby wells. <br /> n At least 4ore than <br /> xxxx None 7 one one <br /> COLUMN TOTALS>>>TOTAL POINTS + agpt, 407 <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or mare 41 or less <br /> I r7 W 7,� � B T X E 8 TMAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 <br /> ample Result; <br /> GASOLINE 1000 <br /> ,�( IMJM ALLOWABLE TPH LEVELS (PPM) 100 10 <br /> V _TPH IESEL 10,000 1000 100 <br /> FOOTNOTES: ***!f documented soil and/or ground water contamination is present, do not canplete the leaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or <br /> L If depth is > 5 ft. and < 25 ft. score 0 ground water.) <br /> points. If depth <=5 ft., do not use table. <br /> L If precipitation is > 40 inches, score 0 points. <br /> J3 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline)) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION 47 't�yUo) <br /> 1. Are BTX $ E or TPH Concentrations > Allowable Levels Yes o <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 G1 / A / (� ATE LOSURE LETTER MAILED <br /> AME OF <br /> -VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />