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SAN SOA 1N Moog PUS IC HEALTH SERVICES/EWIRONMENTAL REAL k"'01VI SION <br /> UOST WORKSKET FOR SITE CLOSURE EVALUATION ATE <br /> AME Of FACILITY dG fps coos <br /> 00RESS ARK 10 # <br /> ANN SIZE <br /> 11. GENERAL SITE HISTORY <br /> colt 0$ sr <br /> n9l Ouet <br /> 111. TANK HISTORY <br /> s lank testetiy to sited re iSi test f yes, give date($) <br /> as a repair "ired? <br /> As repair irrssti ere spit eraaattedT e <br /> IVAEMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Sa"Ptes R verage Annual Precipitation 4 0-25 <br /> -Site woM$ <br /> S core S Coro S Coro <br /> Isrante to we C 0 PIS C pts C pts <br /> 0 if 0 if 0 <br /> R ondition it anditicn R <br /> Site Feature - teaching Potential, Analysis E s awt e is met e <br /> im1mvm Depth to grow-dwater from the Soit Sete-(feet) >100 1-100 8 -5011 <br /> ractures in subsurface (applies to foothills or mountain areas) NoneR resent <br /> verago ArrAjat Precipitation (inches) xxxxx '410 9 10.25 Kxxxxxx 26-4012 <br /> -Made conduits which increase vertical migration <br /> leachate (i.e., Septic syszous, water watts, ponds) None Unknown resent <br /> Inique site features: Recharge area, tests* snit, nearby wetts. At least ore than <br /> xxxx None one one <br /> COLUMN TOTALS­TOTAL POINTS + /91 + 23 <br /> ample Resutt: IS T X OR E) RANGE OF TOTAL POINTS PIS or more 41 - 48 pts 40 pts or tess <br /> 8 1 X E 8 1 X E <br /> MAXI" ALL 1 50 50 50 .3 .3 1. 1. NA\3 <br /> ampLe Result.* AROLINE 1000 100 10 <br /> AXI" ALLOWAOL <br /> TPH t SEt 10,000 1000 100 <br /> OOTNOTES- If docurented soft and/or ground water contamination Is present, do not cwptete the teaching pot tilt <br /> analysis. (i.e., site is currently on LIST Contamination List,for soft or ground water.) <br /> 11 if depth is > 5 ft. and < 25 ft., score 0 points-� if depth <25 ft., do not use tabte. <br /> \2 if precipitation is ), 40 inches, score 0 points. <br /> a TPH concentration of 10 piac Tgasotige) or 100 dieset). <br /> Vt. STAfF WOWENOATION/CONCLUS ION <br /> Vtl. PEVIEW EVALUATION - TO BE'CC14PLETEO BY A SUPERVISOR/SENIOR <br /> .ONCUR WITH STAFF RECO14MENOATION FOR CLOSURE ES 0 EFERRED TO SITE MiTICATION FOR EVALUATION ES 0 <br /> ATE REFERRED )ATE CLOSURE LETTER MAILED <br /> 4AME Of <br /> .VALUATOR <br /> EN 23 80 (UGTWKShT)\5/90 <br /> ,EH 29 80 <br />