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SAN .1CACUIN ITY PUBLIC HEALTH SavTCS/ENVIRCNMENTAL 4EA ` DIVISZCM( IOA7E/�— <br /> I �.,ST vORKSNEET :•CR siic C.CSURE )ALUATICN <br /> ISLE°s =E! <br /> NAME OF ;ACIL:TY a <br /> (TANK (O <br /> ACORESSI <br /> TANK S[ZEI (FU�1, <br /> II. GVE.RAL SITE 4ISTCR7 <br /> � [sIYes� Nel (Permit 3I .Facility Sams CoCd del O r IOce.Sei L/ CantlYes <br /> ennit Current? l INoI <br /> Vureer of Tanks at facility) IA9e or IWks(ir mi[aele)I - IType of iarmi SteetlEr3LI IS.9LI Owll <br /> :II. TANK 4ISTCRY <br /> vas lank ^.ested7lYesl NaI (Failed precision :est l�Yesl INoI IIf yes, give date(s)I <br /> .as a repair made to the -Jr* systmOlYesl NoI If Yes, vnat las repaired!( <br /> .':as repair done under inspeCti on?i Yes l INoI Iters soil saaoles analyzedllYesI INoI ISTXEI ITPH-GI ITPN 71 Ipwas1 I <br /> -)ce of 'ai lures/discharyel Imtascraoniel Ilang-teno leaka9el Ioverfild Iu+kr+arnl IoC.er: <br /> :V. IF-MOVAL 4ISTCRY (ATTACH INSPECTICH REPORT FOR SITE OEi AILS/CLL=C• OATH RR LE1C3ING ?0T"e4TIAL ANAL•.SIS) <br /> � ,,rrAverage Annual ?recipitatieni A= 14 15_I <br /> 0- <br /> iSoiL -a,oOles ReCeiyed l Yesptn l NE IOe :o Ground Yaterilk Ref/' lmi I I 1 <br /> ICr-iita uel L(s)I YesIXNeI INtmmr i 7ypel Iirri OmI IPuoI ; score S Sara 'a Score <br /> Oistanca m vel L(s) from 7ank1,22�ft; 22.�5_4t; C t0 Pu C 9 Pts C 5 pts <br /> O if C iT I D if <br /> R cmnai ti Orl 3 eltdt tlOn g C91d1 Li an <br /> IV. Site Feature - Leaching ?ecential Analysis �is moo I _ his neo _ is act <br /> (Minimus Oepth m 3roune+ater cram Fre Soil Smote (feeU'�(j--�.3_><cSl I >t00 I I5.-ICO I I. 5-i0\t <br /> in ssurface Cacpli' m feotnills or :. tain ar_ss) I I .Vose I "rvnrn (Present <br /> ub <br /> Average Annual ?raci pian an (itches) ISI <10 I 9 I :C-5 Imo) <br /> Man-Made ccncuits unich ind.-aase veRiC31 sigration <br /> 'Jf LeeCiate (i.e., sem4c systems. '•nicer tells, acnes) ( Name Ultki:Caa1 4Present <br /> Unique site features: jecnarge area, coarse sail, nearny 'alts. � I I ` / I At l am iMarc we <br /> I ore /7CQ`' <br /> COLL94N TCTALSA»TOTAL POINTS <br /> ISamole Resu L-: (B X OR _) RAN,CE OF TorAL PCINTS14.9 pcs or more I 4.1 :3 pts ,.pts or l <br /> iKl All 17} D 3 x 3 1 T x <br /> IS P i MAXIMUM ALLaAOLE 3-r-X-- LEVELS (FOM) 1� 501 50� 50 .3 a <br /> Sande Result: GASOLINE 1000 I 100 I 10 <br /> MAXIMUM ALLMML£ TPN LEVELS (PPM) <br /> r\ V YPH OTESEL t0,000 I 1000 I 100 <br /> FOOTNOTES: —if d=joemed soil and/or ground '"ter contamination is Present, do net CORolete Ore 'earning potsnci at <br /> Contaminationanalysis. (i.e., site is currently on UGT Contamination List for soil ar grmad <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth =5 ft., do not use table_ <br /> \Z If precipitation is > AO inches, scot 0 points. <br /> V Levels for 3TXSE are rot applicable at a TPM cor=mCratfan of t0 ppb (gasoline) or 100 ppm Cdiesel). <br /> vI. iTAFF .REC(74MEVOATICN/CQICiUStCN L'O' <br /> 1. Are 3TX 3 E or TPN Concentrations > Allowbie Lavets I"'esI INo} <br /> ?- ieconmer+d Site C:asurelye,l INoI �lf Yes, Refer to Site Ni Llgar an far _valuation Ch• l: J <br /> VII. 7EVIEL EVALLIATICN - 70 3E =WL''I0 SY A SUPERVISOR/SENICR <br /> CHCJR uITH STAFF tECCM'IEYDATICN FOA ^=aSIREIYESI N01 REF=_UED i0 SITE HITIGATICH FM EVALUATICNIYESI UNCI <br /> DATE .REFERREDI / / OAT'e CCSTURE L_--7a ! mmi / / I <br /> NAME CF <br /> VALUATCRI <br /> EH 3 30 (UGTLKSHT)\:/40 <br />