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SAN .lOACUIN CCLIXT7 e��..��....��C HEALTH SERVICES/ENVIRONMENTAL HEALTH OI`VIN ATE <br /> UGST LCRXSHEET FOR SITE CLOSURE EVALUATION /Q-ZZ <br /> nME Of FACILITY7- �- 'EEPS CODE <br /> OGRESS �`-� _ ANX IO 9 - <br /> TANK SIZE �(� UEL TYPE I UN <br /> :1. GENERAL SITE HISTORY <br /> Is Permit currenC7 as a ermit s acility Status Code oc.Sail/GW ConC es o <br /> unber of Tanks at facility ge of Tanks(if available) ype of tank teal brgl ngI Dual <br /> III. TANK HISTORY <br /> as Tank tested7 as o ailed precision test T es o 1f yes, <br /> as a repair ,made to the tank system? I as <br /> No f yes, what was repaired? <br /> 'As repair done under inspection? as o ere Soil samples one ly%ed7 as o TICE ON-G PH•0 b/E08 <br /> Type of faiLure/discharge atastrophic long-term leakage verfill noun Cher- <br /> W. REMOVAL 41STCRY (ATTACH INSPECTION REPORT FOR SITE OETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received as o11 epth to Grotmd Vater Year ;$ verage Arcual Precipitation I = G 0-25 <br /> Site 'Jell(s) es o Later d Type Ire 9m b S care S core S core <br /> is:ante to Wells) frac Tank ft; -f C; ft C 0 Pts C pts C pts <br /> O if O if 0 f <br /> R audition R ondition R ondition <br /> I • <br /> Site Feature - Leaching Potential Analysis E 's mac E is met E 's mac <br /> I inimmm Depth to groLdwater from the Soil Sade (feet) ./ >100 i-100 25-50\1 <br /> brsctures in subsurface (applies to foothills or motmcain areas) Nine Unknown resent <br /> avcrage Arcual Precipitation (inches) xxxx <10 9 10-25 szzxxx 26•4O\2 <br /> 4an-4ade =rcuits t,hich increase vertical migration � <br /> � f leachate (i.e., septic systemponds) <br /> s, water wells, None 4� Unknown resent <br /> iwe site features: Recharge area, coarse soil, nearby wells. lll� I At least ore than <br /> x=x Hone one one <br /> COLUMN TOTALS>>>TOTAL POINTS U <br /> ample Result• 8 T X OR E) RANGE Of TOTAL POINTS 9 pts or more 41 - 48 PCs GO pts or less <br /> d T X E 8 T X E <br /> \� HAXIHLH ALLOWABLE 3-T•X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> angle Result: SOLINE 1000 100 10 <br /> �40114UH ALLOWABLE TPH LEVELS (PPM) 100 <br /> TPN IESEI 10,000 1000 <br /> COTXOTES: If documented soil and/or ground water contaeination is Present, do not complete the Leaching potential <br /> amtysis. (i.e., site is currently on UG1 Contaaination List for sail or ground water.) <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth 4a5 ft., do mt use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for 3TXSE are not applicable at a TPN concentration of 10 Ppm (gasoline) or 100 ppm (dieset). <br /> :. STAFF RECCWE40ATIOH/CCNCLUSION <br /> 1. Are 3TX 1, E or TPH Concentrations > Allowable Levels Yes o � <br /> 2. Recomnerd Site Closure es o If Yes, Refer to Site Mitigation for Evalwtion �/ <br /> 'I. REVIEW EVALUATICN - TO 3E C PLETED 3T A SUPERVISOR/SENIOR <br /> DNCUR WITH STAFF RECOMMENDATION FOR CLOSURE SES EFERRED TO SITE NITICATICH FOR EVALUATICN YES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER !AILED f <br /> LAME OF <br /> :VALUATOR <br /> CN 23 30 (UGTVKSHT)\5/9 <br />