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OF FACILITY <br />TANK SIZEf 0 ayD__ <br />II. CEHERAL SITE HISTORY <br />[s permit current?IYes� <br />.Horner of Tanks at facil <br />SAN JCACUIN # PUSLCC NEALTX 5E7VICS/E4VIRCNMENTAL iEA <br />'JCRKSHE_i PCR Slim C.OSURE _/ALLLITICN WVISCCNOATS <br />TANK 10 <br />FUEL YPE f ir+�, j V/U, 175 <br />I Faci liy Salts Cadel (01�1IOaLLc.Soi UGI <br />Age of Tanks(if available)I '( ]14NTYPe of Tankl Stet lFbrgLl <br />;I. TANG nlo�unr <br />vas 'ank ZeSted?IYes NCI IFai Led precision :est ?IYes I INC' IIf yes. Sive date(s)I <br />repair made :o the :ank sysicafllyesl MoI If yes, vnat vas remi rec?I <br />;':as repair done ,rider inspec:ian?Iyo III'Jars sail samoLes analyzed? Nei INoI STXEI ITPX-GI TPN ­31 IPb/E08I <br />"ype of failure/discnargel <br />ICatastromicl ILong-term leakage) <br />(Ref/Pearl <br />IaverfiLLI <br />Iladmowl <br />Iocter. <br />C/ ZE40VAL HISTORY (ATTACH INSPECTION REPORT FCR Si Tt 1�1� ^^ ^•-• •_._...._ <br />SoiL Samples .Reeaivedl <br />Yesl <br />INoI <br />Ioepth :o Ground Vaterl <br />(Ref/Pearl <br />(Average Amual 7reeipi :atianIA=I <br />14 I10-ZSI <br />Cn-Size 'JeU(s)Iyes <br />No <br />"'Un i TYpel <br />Ilrrl <br />IOam) ISI <br />S <br />C <br />0 <br />i <br />- <br />Scare <br />10 pts <br />if <br />candi Lien <br />is met <br />S <br />C <br />G <br />.R <br />E <br />Sure <br />9 pss <br />if <br />Candi ti on <br />is net <br />'a <br />C <br />C <br />R <br />Score <br />5 pss <br />if <br />condition <br />�Oistance :a Jell(s) from Tankl ft; <br />IV. Site Feature - Leaching Potential Analysis <br />mlmjm Gepih :o grourwarar 'ram "-"e Soil L=Le (feet) I <br />IP^oc:ures in sucsurface (applies to foothills or .mountain areas) I <br />I <br />>100 I <br />` Norte I <br />I5i-000 l 125-50\t <br />l Unknown I IPr-sent <br />)Average Annual Precipitation (ic=es) I;pcaxxl <br />d0 <br />I 9 <br />I Ta -25 Izcco=1 75-4442 I <br />'Man -Made conduits whici inoreese verbcol ni 9rati an I <br />:of leachate (i.e., septic systesm, eater •+mils, paras) <br />I <br />Mane <br />I <br />I Unknown I Present <br />�Uni Cue site Features: ieetarge area, coarse sail, nears/ 'ills. I <br />I <br />SI <br />Harte <br />I <br />I At least) More than <br />one one <br />I COLUMN TOTALS»>i OTA" POINTS I <br />I <br />I I Ia <br />I�%ej 3@uy^ n ' f�1 OR _) .7ANfm OF 'OTAL POINT 5�49 <br />{ K I S Z ,NV J MAXINIm ALLWASL= 3 -i -Y -z LEVErS (PPM) <br />pis or mare <br />I 47 - AS pcs ( 40 pts or less <br />tI i0 i0I 50 <br />I 3 .3 I t.I 1. MAV <br />Sample Result: <br />N� MAXI" AL,.OYASLE TPR _VELS (PPM) <br />rPx <br />GASOLINE <br />1000 <br />I 100 I 10 <br />or: <br />1a,OW <br />I Leap i 100 <br />F TNOTES: ^'If doeumcted soil and/or grvls"d eater cantaminarion is present, do not caclete c"e leading potential <br />analysis- (i.e., site is currently on Uq, Convminatian List for soil or ground water.) <br />\1 If depth is > 5 ft. and 4 25 ft., score 0 points. If dept" �5 ft-, do not use table - <br />\2 If precipitation is > 40 inches, sore 0 Paine_ <br />\3 Levels for 3TXSE are nor applicable at a rPx ora:areration of 10 ppa (Sasoi ire] or 100 ppm (diesei). <br />VI. STAFF RECUAMENOATICN/C�µ(/� <br />NCLUSICN 6a4 k sxcet G'.S7UL " Low .PQ,"".(y.,�/t-4 1DI'J'"'� -`U"� <br />1. Ara 3TX 3 E ar TPX Conces"traiiana > <br />Womble Levels I-Yesl IHa T K I ' V _ <br />jK►S <br />Z. Reccufnend site Ctosurelyes Nal �"If Yes, Refer to site Mitigation for :valuation K n .1 I. <br />VII. REVIE] EVALUATCCH ' 'C 3E COMPLETE 3Y A SUPERVISCR/SEXICR p"ry W i <br />I CNCUR wl iH STAFF REiCMMEMOATICN FCR .^.OSi1RE I YES!—yy I IREFEtREO TD SC%MITTGATCCII PCR=/ALLATIONIYESI �N01 l - <br />DATE REFERRED I TE CLaMRE L--rTa .XAILE-31 <br />NAME OF i <br />EIAIUATCRI <br />EH 3 30 (UGTUK3HT)\5/90 L.<, &d'` O G Kp I e ' S "S t • �"e o f <br />ae 3a. 6ol <br />