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SAN 10ACU[H Ca' PUBLIC HEALTH SERVICES/EHVIRCHMEYTAL REALiv LVLSIGN <br />WCRKSHEci FOR SIT= CLOSURE EVALUATION IOATEI /J <br />NAME OF FACILITY f Vw /I'U�n A SJE='S CCOE� <br />TA / _ 7 Al A. <br />TANK Si2EI /0 &1" 1FUCL TYPEI 4i <br />(I. GENERAL SITE HISTORY w <br />Its permit current?lyes Hal 1Perait 3l Facility Satter Codel 1Dae.SaiL/GW Cant IYes <br />�Ntancer of Tanks it faciLityl IAge of ianks(if avai Labte)l (Type of Tankl SteeLl lFbrgtl ISngt1 <br />TANK HISTORY <br />.Was lank tested?IYes Ictal lFai Led precision test ?IYesl INoI IIf yes, give care(s)I <br />'.as 3 repair made to the tank System? Yes Nol IIf yes, what was repaired71 <br />;':as repair done under inspectimRlYes® <br />l INaI IWert sail salas analyzed?YesNa{ BTXEI ITPX-GI <br />Tyre of failure/discharges Icatastrcrniel (long - term Leakage) Iaverfilll Iurium+an' latter: <br />ill. 1EMOVAL HISTORY (ATTACH INSPECTION iEPORT FOR SITE DETAILS/C7LL=CT DATA FOR LFACETING POT-cVTIAL ANALYSIS) <br />OuaL <br />Sail SaamLes ReceivedlYasI INoI <br />Oeoch to Ground 'Jaterl <br />IRef/YearI )Average Anneal PrecipitatianlA=I <br />14 110-5 I <br />Cn-Sire 'WeIL(s)I <br />Yes <br />1 1Me 1Hn <br />r i type) <br />llrrl OaoI IPUZI <br />5 <br />Co <br />0 <br />A <br />E <br />Scare <br />pu <br />it <br />omditiani <br />�is mac <br />S <br />C <br />D <br />l E <br />Scare <br />9 ats <br />it <br />condition <br />is aec <br />'a <br />C <br />a <br />R <br />Sere <br />5 pts <br />if <br />condition <br />is ere <br />Distance to 'Wetl(s) frau Tankl fc;ft, <br />IV. Site Feacure - Leaching Pateacial Analysis <br />Minimus oeoth -a graunmuter Tram rhe Sail Sample (feet) <br />+ <br />l >100 <br />1 <br />IS) -7C0 <br />l ZS -50\T <br />iF^azures in sudsurface (a:pties to fmchills or a, Cain areas) <br />I <br />None <br />( <br />I Unknown <br />IPrasent I <br />iAver3ge Annual Precipitation (inches) <br />j===l <br /><10 <br />1 9 <br />1 la -:5 lsxzcaXl <br />25-44\2 <br />'Man -Made conduits which increase verriciL aigrationi <br />sof Leachate (i.e., septic systems, wcer •ills, pones) <br />I <br />I Norte <br />I <br />Unkrawn i <br />Present: <br />�Unicue size features: .iecnarge area, coarse sai L, rearoy vel Ls. <br />)Lt[:CL< <br />I <br />I <br />.Herne <br />I <br />I At Least) <br />On <br />i <br />Mare than <br />we <br />IC7llAIM iaTAi.9»TOTAL POINTS <br />Saniele lesutr: (3 T X OR _) RANGE OF TOTAL POLN175+49 <br />,1Ka N = !U <br />�r .g S 3 ND MAXIMIRM ALLOWABLE 3 -7 -X -i: LC /ES (PPM) <br />pis ar we <br />1 61 - 4-a its :0 pts or Less <br />3I i0� i0` 50 <br />- <br />I -3 I.3 I ;.I 1. NA\3 <br />: Saac(e ResuLz: GASOLINE <br />N71 IUXI" ALLOWABLE TPH LEVELS CPPM) <br />,V TPH DIES'' <br />1000 <br />I 100 I t0 1 <br />70,000 <br />I 1000 I 100 I <br />FOOTNOTES: ^IIf docmmrted sail and/or ground 'ester Caltaminatian is Pment, co not Ca®tater the '.meIIing pacmc". <br />a,,Lysis. (i.s., site is =rrencty on UGT Conrmsinatim List far sail or gronsrd water.) <br />\1 If depth is > 5 ft. and < 25 ft., score O points- If death =5 ft., do herr Use table. <br />\2 If precipitation is > LO inches, score 0 paints. <br />\3 Levels far 3TXSE arc ms 3PPt icabte at a TPN altoahcratim of to ppm (gasoline) or TDO ppm Cdi esel ). <br />i <br />VI. STAFF .RECI24MENDATION/CCHC ISION <br />71. Are 3TX 3 E or TPH Concentrations > ALLowabte levels I1fas+ No <br />2. <br />1 <br />2. 3ecatnoend Site Closur_iYesINaI 1-'tf Yes, Refer ro Site Mitigation for Evatwcion <br />VII. iEVIEW EVALUATICH - TO 3E COMPLETED BY A SUPERVISOR/SEHICR <br />C.vCUR WITH STAFF RECOMMENDATION FOR CL05UREIMI 1401 IREFERNE7 TO SITE .MITIGATION FOR EYALWITICNIYESI INaI <br />GATE .IEFERREDI / / IOATE CLOSURE LETTER //�MAIL7l / / <br />NAME OF %-� 0 .4 <br />EH n 110 (UGTWXSHT)\5/90 <br />