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SAH s0AQUIH CCLINT',✓ �BLIC HEALTH SERVICES/ENVIRCNMENTAL HEALTH ' -SIOH ATr� <br /> I ii UGSi !XSHEET FOR SITE CLOSURE EVALUATIONj <br /> ZL <br /> EPS COOEnME OF FACILITY ` � � JJnORESS - t�Gv 1 0— ANX 10 $ Z4e?7 <br /> IANX SIZE G � UEL TYPE I V. 4, C <br /> 11. GENERAL SITE HISTORY " '• <br /> Is permit current? es o ermit - acility Status Code oc.Soil/GW Cont es o <br /> unber of Tanks at facility ge of Tanks(if available) ype of Tank tee! Erg! rgl Dual a <br /> i <br /> III. TANK HISTORY <br /> Jas Tank tested? as o ailed precision test 7 des o it yes, <br /> give date(s) <br /> as a repair made to the tan system? as Ha f yes, chat watrepailred? <br /> 'as repair done under inspection? eS o ere soil samples aes o TXI3 PH=C PH DIr ype of failure/discharge atastrophic tong-term leakage " vk own trier: <br /> MV, REMOVAL HISTORY (ATTACH INSPECTIOW REPORT FOR SITE DETAILS/COLLECT DATA f."R LEACHING POTENTIAL ANALYSIS) <br /> ° �� verage Annual Precipitation = 4 0-25 <br /> cit Samples Received es a epth to Ground water / of/Year - <br /> -Site Well es o umber b Type Irr ! om b <br /> S core S core S core <br /> .—ft; ft C 0 pts C pts C pts <br /> istance to Vell(s) from Tank ft: — ; 0 if 0 if 0 f <br /> R condition R ondition R audition <br /> 1. Site Feature - Leaching Potential Analysis <br /> E is met E is met ti s met <br /> inimum Depth to groundwater from th'e Soi[ Sartple [feet) ; /,/p <br /> rim >100 1-100 '?: 25-50\1. <br /> Fractures in subsurface (applies to 'foothills or mountain areas) <br /> Hone Unknown resent <br /> vcrage Annual Precipitation (inches] I xxx <10 4 t0-25 xxxxxx 25.4012 <br /> an-Rade conduits >+hich increase ver;ltical migration None Unknown resent <br /> I leachate (i.e., septic systems, water wells, ponds) <br /> At least ore than <br /> ique site features: Recharge area, coarse soil, nearby .wells. ogre one; <br /> Kxxxxx . None <br /> COLUMN TOTALS,"TOTAL POINTS <br /> a le Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 ptsj> 40 pts or less <br /> =NA•o! r'f�'1 �:NDS P <br /> Xy f.g p MAXIXLH ALLOWABLE a-T-%-E LEVELS (PFM) 1 50 50 50 .3 .3 1. 1: NA\3 <br /> !' SOL IPIE 1000 100 IQ <br /> ample Result: I - <br /> AXIMUM ALLOWABLE TPR LEVELS (PPM) 10Q, <br /> fvpp _TPH—G d fESEL 10,000 1000 <br /> I <br /> FOOTNOTES: •'•If documented,ait and/or ground water contamination is present, do not complete the teaching potential " <br /> aralysis:' (f.e., site is currentty on UGT Contamination List for sail or ground water.) <br /> \1 If depth is > 5 'lft, and < 25 ft., score 0 points. If depth <=5. ft., do not use table. <br /> \2 If precipitatiori-is > 40 inches, score 0 points. <br /> \3 Levels for 8TX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or"100 ppm "(diesel). <br /> VI. STAFF RECCWSNDATION/CCNCLUSIOH -T- <br /> 1. <br /> 7 1. Are BTX & S or TPN Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure Yes o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE CCMPLETED BY A SUPERVISOR/SEHIOR <br /> GNCUR WITH STAFF RECOMMENDATION FOR CLOSURE SES O,i EFERREO TO SITE MITIGATION FOR EVALUATION ES O <br /> ATE REFERRED / / " " ATE CLOSURE LETTER MAILED <br /> IAME OF �. <br /> ;VALUATOR <br /> r <br /> EH 23 90 (UGTWKSHT)\5/90 ` <br /> 4 J <br /> III Y. Ir, J <br />