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SAN dmf`.. -iN CLVNTY PUBLIC HEALTH SERVICESMWtRONMENrHEALTH DIVISION <br /> I, y UST 1d0RKSHEET FOR SITE CLOSURE EVALUATIaIf ATE 7•_ % <br /> AME OF FACILITY 7 1"RD v' �� S. / CCstD 10 <br /> OORESSI ANK ID r€ 1 ' I iT I.:) f r✓ <br /> i, <br /> AHK SIZE 00C) L TYPE P" rt/ <br /> II. GENERAL SITE HISTORY <br /> Is permit current? es a ermit - aciLity Status Code oc.SoiVGW Cant Yes a <br /> umber of Tanks at facility ge of Tank(if avaiLabte) ype of Tank teel rgl ngi Dual <br /> III. TANK HISTORY <br /> as Tank tested? es o ailed precision test ? as a If yes, give date(s) <br /> Jas a repair made to the tank syszem7 es No 11f yes, what was repaired? <br /> as repair done under inspection? � es a ere soil samples analyzed? es o TXE �PH-G PH-Q 4/EDB <br /> Type of failure/discharge atastrophic long-term Leakage iEL ther: <br /> IV. RE4CVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oiL Samples Received es o epth to Ground Water IAlef/Year 8(O verage A Precipitation = 4 0-25 <br /> n-Site WeIL(s) es a umber & Type Irr f <br /> Score S care S care <br /> istanc_ to Wet L(s) from Tank ft; ft; ft C 0 pts C pts C pts <br /> Q -f 0 if 0 :-f <br /> R onditicn R randition R onditicn <br /> ` . Site Feature - Leaching Potential Analysis E s met E is abet E s met <br /> inirrusn Oepth to groundwater from the Sail Sample (fest) z/ l J >100 i-100 25-50\1 <br /> rac:uras in subsurface (applies ca foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) a== <10 9' 10-25 =xxxxx I26-40\? <br /> an-made conduits which increase vertical aigration <br /> f Leachate (i-e., septic systems, water wells, ponds) { None Unknown Present <br /> nicve site features: Recharge area, coarse sail, or wells. + p At least 4ore than <br /> Cmuncipal= 2000 ft; domestic-- 500 ft; irr/agricuEturat=presentl Kane I one one <br /> COLUMN TOTALS»TOTAL POINTS I p� 7 f 3 7 <br /> ample Result: (8 T X OR E) RANGE OF TOTAL POINTS 9 pts or bore 41 - 48 pts 40 s or Less <br /> B T X LS� B TX i;MAXI" ALLOWABLE B-T-X-E LEVELS (PAM) t 50 50 .3 _3 1:- 1_ / NAl3 <br /> emote Result: INE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH rESEL 10,000 1000 100 <br /> 007NOTE5: *'—If documented soil and/or ground water contamination is present, do not complete the leach entia[ <br /> analysis. (i.e., site is currently an UGT Contamination List for soil or ground water.) <br /> L if depth is > 5 ft. and < 25 ft., score 0 points. If depth Q5 ft., do not use table. <br /> L If precipitation is > 40 inches, scare 0 points, <br /> L3Levels for BTXSE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI_ STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are 3TX & E or TPH Concentrations > Allowable Levels es I o <br /> 2. Recommend Site Ctosure es a If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEU EVALUATION - TO SE COMPLETED 9Y A SUPERVISOR/ 9M SENIOR <br /> CNCUR JITH STAFF RECOMMENDATION FOR CLOSURE ES EFERRED TO SITE MITIGATION FOR EVALUATION �ES O <br /> ATE REF`RRRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> 'IAL UATOR <br /> =_H 23 80 (UGTWKSHT)\5/94 <br />