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SAN JQAQUI NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H DIVISION <br />I, UGST WORKSHEET FOR SITE CLOSURE EVALUATIOR _ DATE <br />NAME OF FACILITY I J (SWEEPS CODE <br />ADDRESS /TANK ID - <br />s <br />TANK SIZE FUEL TYPE" <br />GENERAL SITE HISTORY <br />s permit current? Yes No Permit * - Facility Status Code Ooc.SoiLlGW Cont Yes No <br />umber of Tanks at facitityl Age of Tanks(if available) Type of Tank +Steel I Fbrgl I Sngl Dual <br />III. TANK HISTORY <br />Was Tank tested? Yes <br />Yes <br />No <br />Failed precision test ? Yes <br />Depth to Ground Water <br />No <br />If yes, give dates) <br />/ <br />Was a repair made to the tank system? <br />Yes <br />No <br />if yes, what was repaired? <br />was repair done under inspection? Yes <br />No Number & Type Irr <br />No <br />Were soil samples analyzed? Yes <br />NoBTXE <br />TPH-G <br />TPH-D <br />Pb/EDB <br />Type of failure/discharge <br />Iatastrophic <br />(long -tern Leakage <br />overfill <br />unknown <br />other: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />Soil Samples Received <br />Yes <br />No <br />Depth to Ground Water <br />Ref/Year <br />Average Annual Precipitation <br />A= <br />14 <br />10-25 <br />On -Site WeLL(S) <br />Yes <br />No Number & Type Irr <br />Dom <br />Publ <br />S <br />Score <br />10 pts <br />S <br />C <br />Score <br />9 pts <br />S <br />C <br />Score <br />5 pts <br />Distance to Wells) from Tank ft; ft; ft C <br />0 <br />if <br />condition <br />is met <br />0 <br />R <br />E <br />if <br />condition <br />is met <br />0 <br />R <br />E <br />if <br />condition <br />is met <br />R <br />V. Site Feature - Leaching Potential Analysis E <br />Minimum to groundwater from the Soil Sample (feet) <br />>100 <br />I (51-100 <br />I <br />1.25-50\1 <br />Fractures in subsurface (applies to foothills or mountain areas) <br />I None <br />I <br />Unknown <br />Present <br />Average Annual Precipitation (itches) xxxxxx <br /><10 <br />9 1 <br />10-25 <br />Ixxxxxxx <br />26-40\2 <br />Man -Made conduits which increase vertical migration <br />of leachate (i.e., septic systems, water wells, ponds) <br />Norte <br />Unknown <br />Present <br />Unique site features: Recharge area, coarse soil, nearby wells. <br />( <br />At least <br />More than <br />xxxxxx <br />None <br />one <br />one <br />COLUMN TOTALS»>TOTAL POINTS <br />+ <br />I <br />Sample Result: (B T X OR E) <br />RANGE OF TOTAL POINTS 49 pts or more <br />41 - 48 pts <br />40 pts or less <br />B <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) <br />50 <br />50 50 <br />I .3 I.3 <br />1.1 1. <br />NA\3 <br />Sample Result: <br />GASOLINE 1000 <br />100 <br />10 <br />MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br />TPH <br />DIESEL 10,000 <br />1000 <br />100 <br />FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the leaching potential <br />analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br />\1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth =5 ft., do not use table. <br />\2 If precipitation is > 40 inches, score 0 points_ <br />\3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br />VI. STAFF RECOMMENDATION/CONCLUSION <br />1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No <br />2. Recommend Site Closure Yes No If Yes, Refer to Site Mitigation for Evaluation <br />r <br />VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br />CONCUR WITH STAFF RECOMMENDATION FOR CLOSUREIYESi N0) (REFERRED TO SITE MITIGATION FOR EVALUATION YES( NO! <br />DATE REFERRED / / DATE CLOSURE LETTER MAILED <br />NAME OF <br />EVALUATORI <br />EH 23 80 (UGTWKSHT)\5/90 .1 <br />