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it <br /> F' ATE <br /> HEALTH SERVICES/EHYIEVALt1ATlON HEALTH <br /> 0lVlSiON <br /> SAH JOAau1N COUNTY PUBLIC EEPS COOS 13 6 3 <br /> iI UGST WORKSHEET FOR SITE CLOSURE 3_a+ <br /> ANK !O # 3 i f 136 <br />=ACILITY I V�►r1. <br /> s I <br /> c� <br /> �C l <br /> U � I _ • <br /> F. 000 `,Q <br /> uEL TYPE �70k(wQ �� a.SoiI/GW tont e5 0 <br /> ` acilitY Status Code rgl ngl Dual <br /> 1,L SITE HISTORY rmit # <br /> i ype of Tank teel <br /> � o <br /> it current? CS ge of Tanks(if available) a� <br /> of Tanks at facility give dates) / <br /> I f yes, <br />(. HISTORY FI ° <br /> ailed precision test ? es <br /> f yes, what was repaired? H_D b/EDB <br /> ink tested? es H-G <br /> NO T%I: <br /> to thel�tank system7 es les analYied? es <br /> repair made ere sail samp er: <br /> es ° nknown <br /> r inspection? verfill <br /> epair done unde `c long-term Leakage ANALYSIS) <br /> atastroph <br /> DATA FOR LEACHING POTENTIAL 4 10-25 <br /> of failure/discharge SITE OETAllS/COLLECT DA nation I <br /> RT FOR O verage Annual Precip <br />{0'dAL HISTORY (ATTACH INSPECTION REPO of/Year <br /> Water tore <br /> r epth to Ground core S <br /> Samples Received IeS ° an ub core S C pts <br /> Irr S C pts O f <br /> d o r & Type C 0 pts if <br />:ite Welt(s) es f 0 ondition <br /> ft; �,ft 0 R onditi� R <br /> ft; �r ondition E s met <br /> from Tank �� R E is met <br /> cants to Wells} E s met 25-50\1 <br /> Pate Analysis >100 <br /> Site feature - Leaching ��2 resent <br /> le (feet) �0- unknown a. <br /> ii mum Depth rouidwater from the Soil Same Hone 40\2 <br /> th to g mountain or 10.25 xxxxxx 26- <br /> F footh i l l5 or �u' 9 <br /> 3ctures in subsurface (app <br /> lies to xxxxx <10 <br /> (inches) resent <br /> crape Annual Precipitation ( Unknown <br /> None are than 3 <br /> I which increase vewaterlwel9setRonds) At least one <br /> In-Made Cando septic systems, one . <br /> leachate (i.e., nearby wells• xxxx None <br /> Recharge area, coarse soil, to 2 r� <br /> pique site feature : �l7 + 1 �7 <br /> I + 7 <br /> »>TOTAL POINTS 41 - 48 pts 40 p <br /> RANGE OF TOTAL POINTS ts or less <br /> ' COLUMN TOTALS is or more <br /> 4 R <br /> B T X E B T X E NA\3 <br /> Sample Result: (B T x OR E)tf"'4 1 5o 50 50 .3 .3 1 1. <br /> t2p�M 7" °%pprA LEVELS (PPM) 10 . <br /> NAD .a5 MAXIMUM ALLOWABLE 3-1 100 <br /> 1000 100 <br /> ASOLlNE 100 <br /> 10,009 1000 <br /> ample Result: AXIMUH ALLOWABLE TPH LEVELS (PPM) IESEL. potential <br /> Tete the leaching R° <br /> p .!TPH on is present, do not camp water.) <br /> water contam�natt. for soil or groin <br /> or round on UGT Contamination Ltst <br /> t**lf docu-mrited soil and/ g currently If depth <=5 ft., do not use table. <br /> OOTNOTES: analysis. 0.e site is ints. (diesel). <br /> > 5 ft. and < 25 ft., scare 0 Po 10 (gasoline) or 100 p1a" <br /> depth is > 40 inches, score 0 points. <br /> \1 l f dep . <br /> \2 I f p <br /> recipitation is applicable at a TPH concentration of <br /> \3 Levels for B1X&E are not app <br /> STAFF RECOMMENDATION/CONCLUSION Yes ° <br /> > Allowable Levels for Evaluation <br /> 1. Are BTx 8 E or TPH Concentrations if Yes, Refer to Site Mit'ga0 0n <br /> nd Site Closure eS ° <br /> z' Recontne RVISOR/SENIOR A SUPEES 0 T <br /> - TO BE COMPLETED BY MITIGATION FOR EVALUATION a <br /> I. REVIEW EVALU�TiON 0 IiFERRED TO SITE <br /> ES <br /> ONCUR WITH SCAFF ON FOR CLOSURE ATE CLOSURE <br /> 1hAiLED f <br /> ATE REFERREDI <br /> AME OF <br /> VALUATOR <br />