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SAM JOA*JIN CCNITY PUBLIC HEALTH SERV ICES/ERVIRO MMENTAL HE LIQ IVJSION <br /> 1, UGST WORKSHEET FOR SITE CL EVALUATION ATE <br /> AME OF FACILITY EEPS COOE <br /> 004FESS ANN 10 <br /> ANY SIZE �L TYPE <br /> I I GENERAL SITE NIS IMY <br /> Cant as 0 <br /> n9t Dual <br /> 111" TANK HISTORY <br /> as tank test if yes, give date(s) <br /> as a repair t the tank sTst Ncs f es sat eras epalred? <br /> AS repair d r ins ti f Bre st lyzed? t0 THE PH-G PH-0 b/E08 <br /> IV. NEM 4AL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECt DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> i <br /> oft saeptes R erage Arvvjol Precipitation 4 0-25 <br /> -Site Wal (s <br /> tore S core S core <br /> istance to we fr Tank ti fti ftC 0 Pts C pts C Pts <br /> 0 f if 0 f <br /> R ondition R andition R ondition <br /> Site Feature - Leaching Potential Anatysis f a met E is met f 6 met <br /> ini"Doth to groundwater from the Soil Sante (feet) "100 1 <br /> 00 <br /> ractures in subsurface (applies to foothftts or mountain areas) None <br /> varage A Precipitation (inches) xxxxx <10 9 10-25 xxxxxxx 26-40%2 <br /> ,an <br /> -made conduits which increase vertical migration <br /> f tea hate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> Inique site features: Recharge area, coarse sell, nearby wells. At least ore than <br /> xxxxx Norve one one <br /> COLUMN T0TALS>),>T0TAL POINTS /0 + + ?3 <br /> 'ample Resutt; L8 T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 ffi48 pts 40 pts or less <br /> E <br /> MAXIM"to" AL 1. NA\3 <br /> awpie Aesutt; 10 <br /> AXIMUM ALL ASIS <br /> TPH 100 <br /> TNN ES: ***If documented soft arx1jor ground water contamination Is present, do not cooplety, the leaching potentlat <br /> rTa r? amatysls. (i.e., site is currently on LIST Contamination List,for soft or ground water.) <br /> If depth is > 5 ft. and < 2S ft., score 0 points. If depth 4=5 ft., do not use table, <br /> 1;4 \2 If precipitation is > 40 Inches, score 0 points. <br /> \3 Levels for STX&E are not AppLicebte at a T concentration of 10 ppm (gasotine) or 100 ppm (dieset). <br /> Vl< STAff RECOWMATIONIC ONCLUSION <br /> V1 I. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> .ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED ATE CLOSURE LETTER MAILED <br /> AME Of <br /> EN 23 80 (UGTWXSHT)\5/90 <br /> EH 29 80 <br />