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r WC HEALTH SERVICES/ENVIRONMENTAL HEAL#VISIOH <br /> SAN IDAcutx DATE <br /> Uv w=SHEET FCR SITE CLOSURE EVALUATION <br /> SWEEPS CODE <br /> NAIME OF fACIL1TY A <br /> / TANK ID <br /> ADDRESS �7✓ <br /> TANK SIZE SSD FUEL TYPE <br /> I. GENERAL SITE HISTORY <br /> Facility Status Code S L Doc.Soil/GV Con Yes No <br /> Is permit current? Y No Penit �jto73to7 <br /> Nurber of Tanks at facility <br /> Age of Tanks(if available) TY:�'e of Tank Steel Fbrg Sngl Ott <br /> .tl. TANK HISTORY <br /> lWas Tank tested? Yes` No Failed paecision test ? Yes <br /> No If yes, give dates) / / + <br /> xIf yes, what was repaired? <br /> iWas a repair Cade to the tank sys <br /> telt Its o <br /> Was repair done urder inspection? Yes <br /> No Were soil maples analyz Ye No BTXE TPH- Tb/ED3 <br /> PN- — P <br /> Type of failure/discharge catastrophic long- <br /> tern leakage overfill uryla�a'i other: <br /> iY. REMOVAL HISTORY (ATTACH INSPECTION REPCRT FOR SITE DETAILS/CC LECT ATA FOR L KING POTENTIAL A)LALYSIS) <br /> Soil Samples Received Yes No Depth to Ground Water ! Ref/'fear ; <br /> Average Arcual Precipitation A- 14 10-25 <br /> Nu�er L Type � Irr Dao Pub g Score S Score <br /> Cn-Site Wells) Y No S Score C 9 pts C 5 pts <br /> ? _ft C 10 pts if <br /> 7 <br /> ft; ft; 0 if 0 if - 0-- <br /> Distance to Well(s) from Tank R condition R condition <br /> R ccnditicn <br /> E is met <br /> E is met E is met <br /> V. Site Feature - Leaching Potential Analysis >100 51_100 O 25-50\1 <br /> IMinimua Depth to grou)dwster frcm the Soil Sample (feet) Noce Present <br /> UnkrAwn <br /> Fractures in subsurface (applies to foothills or mxmtain areas) 26-40\2 <br /> y �� <10 9 10-25 xxxxxXx <br /> Average Annual Precipitation Cinches) <br /> I <br /> ,(�,� r'w5 Pre-sent <br /> it Man-Made cerduits rich increase vertical migration �GNone <br /> of leachate (i.e., septic systems, water wells' p7 <br /> At least � More than <br /> wells. one one site features: Recharge area, coarse soil, nearby xxxx= None fQ� <br /> + / + O : z(5 <br /> COLUMN TOTALS»TOTAL POINTS ( 41 - 48 pts 40'pt or less <br /> RANcE OF TOTAL POINTS 49 pts or more <br /> Sample Result: C3 T X OR E) B T X E <br /> B T X E NA\3 <br /> IML?i ALLWaLE B-T-X-E LEVELS (PPM) 1 50 50I 50 .3 .3 1. 1. <br /> � 10 <br /> GASOLINE 1000 100 <br /> SaMle Result: MAX," kLLCW1A3LE TPH LEVELS (PPM) 1000 100 <br /> DIESEL 10,000 <br /> 7PHtential <br /> **'If documented soil and/or ground water contamination is patient. <br /> do not complete the leaching Po <br /> FOOTNOTES: analysis. (i.e., site is currently on UGT Contamination List for sail or ground water.) <br /> \1 If depth is > 5 ft. and < 25 ft., scare 0 points. If depth �5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. 10 ppm C4asoline) or 100 ppm (diesel). <br /> \3 levels for STXbE are not applicable at a TPH concentration of <br /> vI. STAFF RECcwENDATICN/CONCLUSICN <br /> 1. Are BTX b E or TPH Concentrations <br /> > Atlowable levels *Yes Ho <br /> 2. Recommend Site Closure Yes No <br /> If Yd, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE CCMPLETED BY A SUPERVISCR/SENICR <br /> GCNCJR WITH STAFF 2ECCWENDATICx FCR CLCSUA£ YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> / DATE CLOSURE LETTER MAILED <br /> DATE REFERRED / <br /> NAME OF <br /> EVALUATCR <br /> EH Z3 80 (UGTWKSHT)\5/90 <br />