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r <br /> SAN .ICACUIN =S o0?UBLIC 4EALTN SERVICES/ENVIRONMENTAL 4EALT,'..'o ICN GATE <br /> U:_ 1MSNEE�T/ FCR SITE CLOSURE EVALUATION (y <br /> (NAME OF FACILITY �, \ OUB-"C'p - I..O p,\ c�0T'7 ISVEEPS CCOE '�31SS�j <br /> IADDaessl \ t zt Ml�e l cl Lc�� TANX ID r 3q ' 155 3 -0 <br /> TANX SI2Ei��;o (FUEL PE L.1.'11LClC�C�I <br /> It. "uc ML SITE 41STORT <br /> Its xrsic current) Yes No Perait 1 Oo isS� Facility Status Code C) Doc.Soit/W CwtlYes NoI/ <br /> IMuber of Tanks at faeilityl Age of Tanks(if available) �Q yr Type of Tank Steel Fbrql ISngII Dual <br /> M. TANX 31STCRT ``VV.( <br /> vas LanK testedTlYea1 IND IFai ltd precision test t Yes ,M� Mol IIf yes, give date(s)I / / ; / / <br /> r node to <br /> e tank <br /> , what <br /> s revaired?i <br /> Was repair'done undertiimpec'im7I Yes lyes l No No were i soil sampleswanalyzed?l Teal INoI BTXE TPH-GI ITPH-OI Ph/EDB <br /> Type of failure/discharge Icatastrophic LON-term Leakage) averfilt unknosnl other: <br /> IY. .W CVAL 4ISTORY (ATTACH INSPECTION REPCRT FOR SITE OETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples 3eceived Yes No Depth to Ground Vater:Sd Ret/Yeer iCt,&b Avera9e Arrant Precipitation Aa 14 110-25 <br /> ICn-Site 'Jell(s)IYes!/ INoI Number L Type1 Irrl 0= Pub <br /> S Scare S ScoreS Score <br /> Distance to Well(s) from Tankl fp,Q_ft; _f t; ft C 10 pts C 9 pts C 5 pts <br /> 0 it 0 if 0 if <br /> R condition R cordltion R condition <br /> v. Site Feature • Leaching Potential Analysis E is enc E is ant is met <br /> !Minimam Depth to grousrlwater frog the Soil Sample (feet) I >100 151-100 5 125-50\1 <br /> 'Fractured in subsurface (applies to foothills ac mountain areas) 0 I None I I Unknown I Present <br /> Average Annual Precipitation (inches) x:OOeuxl <10 I 9 10-25 lx=o= 26-40\2 <br /> Man-Nada conduits which increase vertical migration <br /> of :eachare (I.e., septic Systems, water wells, ponds) I None I lk,knavh Present <br /> (Unique site features: Recharge area, terse sail, nearby wells. �? At least) Mare than <br /> Noun 1 am am <br /> =I= TDTALs>WOTAL POINTS ID I • l 6 • JC� I• 3Q <br /> Sample Result: (S T X OR E) RANG-< Of TOTAL POINTS 49 pts or more I 41 41 pts I 40 pts or Less <br /> ND .oeYpr+. <br /> TvDI <br /> NAXIMD( ALLOWABLE 3-T-X-E LEVELS 'PPM) ail 50l 50l 50 .3 .3 I X. <br /> Sample Result: GASOLINE 1000 I 100 I 10 <br /> IMAXIMtx ALLDWBLF TPH LEVELS (PPM) <br /> WTPN DIESEL 10,000 1000 I 100 <br /> FOOTNOTES- —If docwwted soil and/or 91m water contamination is present, do roc eaeolata dhe Leaching potential <br /> analysis. (i.a., 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 a5 ft., do not use table. <br /> j V' \2 It precipitation is > 40 inches, start 0 points. <br /> A \3 Levels for 3TXLE are not applicable at a TPH concentration of 10 ppm (9asolim) or IaO ppm Cdfesel). <br /> 'II. T,��CCSMEVOATION/Ct71C_JSICN �� O lAl� �- <br /> 1. Are 3TX L E or TPH Core CmcAl a Levels I'Te1 INoI <br /> P �p/apwsA.� <br /> Z. Recaimerd Site Ctasarel Yell Mo It Two. Refer dp $ite Mlcigation tar -evaluation <br /> VII. REVtEY _JALUATICN - TO 3E COMPLETED 3T A SWUVIS091SEMICR <br /> CCNM2 'JITN STAFF .2EC0WENDATTC31 FOR CLOSURE IYESI I IREFOWM TO SITE MITIGATION FCA EVALIIATICN I7ESI INC1 <br /> DATE 9EFERRE)I / / (DATE CL=URE L<MER MAILZI / / <br /> I <br /> NAME OF <br /> EVALUATOR <br /> -4 23 30 (UC7ASHT)\5/90 <br />