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if Fr t Ottt!Z 4 6/1 lL -rcL A << a <br /> SAN dOAOI QTY PUHliC HEALTH SERVICES/ NYIRONMENTAL d`DIVISION <br /> I, UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE I Jr <br /> AHE OF FACILITY I Lam- �I/V1�. 0,P6L� i�oUC SWEEPS CODE 1Z <br /> TIDRESS ��(�� 5h(yjTANK IO # fZ:77--0'2- <br /> TANK SIZE jZ UEL TYPE dte5el ° <br /> r <br /> ll. GENERAL SITE HISTORY <br /> Is permit current? as a rmit # cility Status Code oc.Soil/GW Cont IYes <br /> o <br /> umber of Tanks at facility kge of Tanks(if available) IType of Tank IS teet gl ngl Dual <br /> 111. TANK HISTORY revv.C)ved It- 2!•Ct <br /> ,as Tank tested? Ifes o aited precision test ? F;T ilo If yes, give dare(s) <br /> as a repair made to the tank system? Yes No 11f yes, what was repaired? <br /> ,s repair done under inspection7 es o ere soil samples an tyzed? es ao TXE PH.r- PH-D b/EDB <br /> ypc of failure/discharge atastrophic long-term leakage ve fitL nknown 1 10 <br /> ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT CATA FOR LEACHING POTENTIAL ANALYSIS) <br /> .oil Samples Received es o epth to Ground Water of/Ye r verage Annual Precipitation = G 10-25 <br /> -Site WeLI(s) es o umber & Type Irr I cm I ub <br /> S core S Score 5 Score <br /> istance to Wells) from Tank ft; ft; ft 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R ondition R condition Rondition <br /> Site Feature - Leaching Potential Anatysis is met E is met E s met <br />µZ 13,f iniffoom Depth to groundwater from the Soit Sample (feet) >100 1-100 25-50\1 <br /> 13, ractures in subsurface (applies to foothills or mountain areas) None Q Unknown 01resent <br /> verage Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> f teachate (i.e., septic systems, water welts, ponds) None Unknown S resent <br /> Inique site features: Recharge area, coarse soil, nearby welts. At least 4ore than <br /> xxxx None q one one <br /> 2T 5 3Z <br /> $OLUMN TOTALS»>TOTAE POINTS <br /> ample Result: (0 T X OR E) RANGE OF TOTAL POINT 9 pts or more 41 - 48 pts 40 pts or less <br /> K .?f,ppm, <br /> �R T - .05;;f" VI <br /> T X E B T X E <br /> E0 - !-I» MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM 50 50 50 .3 .3 1. 1. NA\3 <br /> -ample Result: wASOLINI 1000 100 10 <br /> 15,mo AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPHpt�►'+�t {E5EL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not camptete 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 HTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION tiVcl <br /> 1, Are BTX & E or TPH Concentrations > Allowable Levels Yes o ~ <br /> 2. Recommend Site Closure es o If Yes, Refer to Site !litigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> _CNCUR WITH STAFF RECCMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION fES10 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> aME OF <br /> ;VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />