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SAN I# i Y PUBLIC HEALTH SERVICES/ 1 Vi t, H t <br /> i. T WORKSHEET FOR SITE tit EVALUATION <br /> r � �4/ ' <br /> AME Qin FAC t t" T r EPS <br /> DORM A Ny <br /> Ali: SI'2E � T <br /> If. GENERAL S.'= C, <br /> ,,s Park to �.4ted precision rest 7 �es 0 If yes, give date�«��# # <br /> _ �y t y �,arh YW j <br /> 'S a a repair R f I+ L � 1i }�i.�7. yes, t was I i t ...«.... .. <br /> toot^9R AWPN'.vMSA.I«77 <br /> f EJ, ,.� Sc rtes r , e ' ;t rfi,C t rra rerfitt r. .. r' 2 >> rs 4 <br /> * MEMOOVAL AISTrrY wAT ACN•. ;0N R:P*!YT F Ic I A L "#' iiAYA f LE�.,,aMG r 3 Nt r§t -1 }... <br /> Wt Received es t r Mater` ef�Yea � A � er���e A Pr�i��ts i� �� it•<i <br /> *I�itp ottts� yes <br /> oror . <br /> ist a t ctot I(.., i°t; ft; eft 0 per. .. s C w <br /> is c diff n Fliltt� :. it cv iti�ub <br /> It fa t~ , .. � Analysis S mot � mit <br /> ini ttsattt tQ � fiCll' <br /> to (feet) )Si Ott1 <br /> ractures subsurfa � A + f thitts or taifi area$)' ! No <br /> YO4184 �t °recipi at m i:l sct es_ x a 410 q' f'I°:! as 6 <br /> rh a a d e 'd L, Wr C I� �e; <br /> f lea chozo tit e_ S &�#" <br /> ep water wells, ) tions U _ r t <br /> Jni sisc a t res;' �zrs wait, nearby 8atta�* m a <br /> ani r r <br /> re A d4 { e f (N 1 <br /> CUlj��4' TC �>TO'AJI POINTS <br /> ill~ gesut t Qin _, R'ANC OF TOTAL POINTS p ws or, :<x re t ,. <br /> T � <br /> 04VI esutts ASOLINE 1000 1 1t1 <br /> ` Z/00 ALL AOL TPN LEVELS ( P ) <br /> Fr, tE 10,00 � ".G+ <br /> OOTN TM ***If �a�t soil and/or grind water, contamination s present, do -*t Atte the tesdair�gratenti t <br /> µ, lysis. e site is currerstty on UGT Contamination List /car soil or ground water.) <br /> \1 If th a ft d < 25 ft., score G points* I depth <=5 ft,, U not taw a. <br /> If precipitation to > -G inches, scorepoints. <br /> Lite for STME are t a ti a le at a TPN concentration of 10 t � or 100 (diesel). <br /> Vt. STAPP' REC - TFC USIA <br /> 1, Are gt E or Concentrations > [[senate Levels Ye <br /> 2. rpt it Cl a If Yes, Refer to Site mitigation for Evaluation] <br /> V11. RE I N EVALUATION - TO I Et) Y SUPERVISOR/SENIOR <br /> » iCURi WITH TAFf � I'm FOR � E ES EFERRED TO SITE MITIGATIONFOR EVAUTATI U <br /> 1 <br /> ATE R FERRE # ATE CLOSURE LETTE MAILED t ! <br /> AME OF <br /> .VALUATOR <br /> ATGR <br /> EN 23 80 (UGT' #T)xS/`9O <br /> H 29 80 <br />