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•"I - SAN .10ACUtN C / LIC HEALTH SERVICES/ENVIRONMENTAL HEAL E9ION <br /> T <br /> U RKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> nME OF�FACILITY G EPS CODE / D F <br /> OORESS' �fi 5� 7p ANK 10 x <br /> TANK SIZE O� UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> if s permit current7 es a ermit N - acidity Status Code ��- «.Sail/GW Conees o <br /> u <br /> I <br /> mber of Tanks at facility ge of Tanks(If available) ype of Tank teal brgl ngl Oual <br /> Ill. TANK HISTORY <br /> Jas Tank tested? es iIii ailed precision, test 7 es o If yes, give date(s) /-. - •-/ / . I: <br /> Jos a repair made to the tank system? es No f yes, what was.repaired? - - -� <br /> .s repair done under inspection? esa ere soil samples analyzed? as o TX E - PN-G PH-D WE08 <br /> ype offailure/discharge atastrophic long-tern leakage verfill known <br /> TION REPORT FOR SITE DETAILS/ LLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> IV. REMOVAL HISTORY (ATTACH tNSPXC <br /> Solt Samples Received o epth to Ground Wale,a Year _ verage Arcual Precipitationr40-25-Site Yet t(s) es o Leber d Type Irr am bS cores core S istante io Well(s) Pram Tank ft; ft; ft C ' O pts C pts C 0 f 0 if 0 R ondition R ondition R 1. Site Feature - Leaching Potential Analysis E 's met E - is met E <br /> tnimun Depth to groundwater from the Soil Sample ?feet) >100 1-100 \1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown esent . <br /> %verage Annual Precipitation (inches) - ;tax 410 9 1 5 xx x 26-60\2 { <br /> Ian-Made conduits which increase vertical. migration - - - <br /> f leachate (i.e., septic systems, water wells, ponds) - - Hone . - Un o - -• resent - <br /> ique site features: Recharge area, coarse soil, nearby wells. A east icre than <br /> IMX=x None one one <br /> i <br /> COLUMN TOTALS>»TOTAL POINTS <br /> ' � (8 T X OR E' �j RANGE OF TOTAL POINTS 9 pts or Inr E` LT - 68 pts 40 pts or less -- <br /> rwly-0-kau+vb /S7)�i�•.- 8 T E 8 T X E <br /> a e Result: <br /> s-- MAXIMLN ALLOWABLE B-T-X-E LEVELS (PPM) 1 SO 0 50 .3 .3 1.' 1. NA\3 - .. <br /> ample Result: - ASOLINE9000 Y• 900 - - :' 10 - <br /> IMUM ALLOWABLE TPN LEVELS (PPM) <br /> TPH IESEL - .10,000.' 1000 100 <br /> OOTHOTES: ...If documented soil a o groundkwate contamination is present; do not complete the.leach irg potential <br /> analysis. (i.e_', � x^e,.. . fly an UGT Contamination List for soil or ground water.) ! <br /> \9 Lidev�ch is > 5 ft erd r 25 f[ score 0 ooin[s If depth <o5 ft-. d. use table, - <br /> F \2 If precipitations > 40 inches, score 0 points.. <br /> \3 Levels for BTX8E are not applicable at a TPH concentration of 10 ppn (gasoline) ar 100 ppm (diesel). <br /> V(. STAFF RECCMMENDATION/CONCLUSION <br /> 1. Are HTX d, E or TPH Concentrations > Allocable levels Tes. o <br /> 2. Recommend Site Closure IT <br /> es o If Yes, Refer to Site Mitigation for Evaluation <br /> Vt1. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSUREES 0 EFERRED TO SiTE NITICATION FOR EVALUATION ES 0 <br /> ATE.REIERREO —(/ / A7E ttOSURE LETTER MAILED ` IF / <br /> +AME OF <br /> :VALUATOR <br /> EH 23 80 (UGTWKSRT)\5/9 - <br />