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SAN ICACUIM CCUI`PUBLIC 4EALT3 SERVIC-S/ERVIRONMEMTAL HEALTIm /!SIOM <br /> I• UGST VORXSHEET FCR SITE CLGSURE EVALUATICM OATE <br /> NAME OF FACILITY C ISWEEPS CODE I 3 ` <br /> ADDRESSI Sf s TANK ID :013 - O <br /> TANK SIZE / FUEL Typ< DAe <br /> It. DEME.RAL ITE HISTCRT <br /> Is permit corrent?IYes No Pamir 3 Facility Stratus Code (5 r 00c.Scil/041 Cont Yes No <br /> (Number of Tanks at facility I (Age of Tanks(if avei table) d n (Type of Tank Steel Fbrgll lSngll - Ouall <br /> III. TAM% HISTORY <br /> Was Tank tested? Yes No Failed precision test 71Yes No If ye, give deco(s) <br /> IWas a repair made to the tank system?IYes l Mo IIf yes, what was repaired? <br /> IWas repair done unCar inspection?IYes I Nol IVere soil samples ana Lyxed?I YeL INoI BTX£ TPH-G ITPH-01 Pb/a <br /> Type of fai Lure/discharge catastrophic tong-tera leakage overfill L untr+owntl other: <br /> (Y. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE OETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> (Soil Samples ReceHE: <br /> ved les XoI Depth to Grand Vater � .D Ref/Tear & ; Average Arsaual Pr*cipitationIAe 14 110-25 <br /> On-Site Watl(s)IYesl No Number 6 type) Irrl Dam pub <br /> S Scare S Score S Scare <br /> IOiscanca to WaLL(s) from Tanis ft; fL; ft C 10pts C 9 pis C 5 pts <br /> o 1f 0 1f 0 if <br /> R condition A condition A condition <br /> Y. Site Fe.eurs Leaching Potential Analysis E is :cot -c is oat E is met <br /> �Minimam Depth to grorsdrater from :he Soil Sample Cfeet)yt)_ 7 l '100 I51-100 25-50\1 <br /> Frac:ure in subsurface (applies to foothills or mountain areas) cel More I I Unknwf I Presena <br /> Average Annual Prsipitation (inches) nCCaxl <10 9 110-25 x=0= Z6-4C\Z <br /> Man-Made conduits which increase vertical migration <br /> of leachate (I.*.. septic systema, water wails, ponds) / 01 Mane Unknomae Present <br /> (Unique site features: Recharge area, coarse sail, nearby wits. AC least) Nor* than <br /> I xxzaa Mori ane <br /> COUIMN TOTALS»iOTAL POINTSO I I �I ' I Ie <br /> Saaole .Result: (S T X CR -c) RANGE OF TOTAL POINTS 49 pts Wpore `. 41 - 48 PCs l 40 pts or les. <br /> ND MAXSMl71 ALLOWABLE 3-T-X-E LL'IELS (PPV) ;I 50I SOI 50 .3 .3 11.I 1. I AW <br /> Saaole Result: GASOLINE 1000 100 I t0 <br /> MAXIlIAI ALLOLLARIE TPI LEVELS (PPV) <br /> X17 TPH DIESEL 10,000 l 1000 l 100 <br /> FOOTNOTES: ^cif documented sail and/or ground water Contamination is present; do rot ==lots the learning Potential <br /> analysis. (i.e., site is currantty on UGT Contamination List for sail or ground water.) <br /> \1 if depth is > 5 ft. and < 25 ft., score 0 points. It depth <a5 ft., do not ume cable. <br /> \Z If precipitation is > 40 inches, scare 0 poincs. <br /> I \3 Lavels for 37X1£ are not applicable at a TPN aancsntration of 10 pia (gasoline) or 100 ppm (dieel). <br /> VI. STAFF RECas0t DAT1Mr/C7(CLUSICM C�C)yyJ .-SQj YI�]L¢.. rOl <br /> 1. Are 3TX i ° or TPI CaneenCrations a Atlamuble levels *Yogi/ INoI AYH lf� 'H'j/Z, <br /> 3 itz-x Nr) <br /> 2. Recommend Sin CLaaurel7el No It Te, icier to Site MfLigatim far EvaluationI C-y <br /> TP(A-a <br /> V[!. .TEYLEV SVALUATIOI - TO 3E cMro1..cTED 3r A 4IDEAVISd!/SENICI! st�',I�-10 Fes.,, I (ea. •.yK X=c .,b -/ <br /> =HC;R WITH STAFF REC:erENDATICH FCR ^.CSURE I YES{ ✓1MCI (REFERRED To SITE NITT6ATICN FOR -EVALUATICRITESjLj�hX3 <br /> OAT; 11i:-EARED I / / IRATE CLGS= L_'TER AIILM I / / I <br /> NAME Of <br /> EVALIUTCR /_T <br /> _H :3 SO (UCTWKSHT)\5/90 <br />