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�t 4 <br /> SAN 30AOl1IN C BLIC WRKSHEETALTH FOR SITEICLOOSURETRONMENTAL EVALUATIONNd1 ISION <br /> , � DATE <br /> i. <br /> 1 . <br /> NAME OF FACILITYef <br /> S sw-EPS CODE OG� <br /> ADORESSI - ' TANK. ID *L3F- Q"—c <br /> TANK S E 2E � '! <br /> FUEL TYPE D j ��/ ;P <br /> 2 D S <br /> [I. G5NERAL SITE HISTORYSfOC� /*/� <br /> Is permit current? Yes No Permit - Facility Status Code Doc.Soil/GLI Cont Yes No <br /> Humber of Tanks at facility Age of Tanks(if available) j/P.1 Type of"Tank Steel X Fbrgl I Sngl DuaL <br /> Ill. TANK HISTORY <br /> Inas Tank tested? Yes . No Failed precision test ? Yes INa If yes, give date(s) <br /> �Nas a repair trade to the tank system? Yes No If yes, what was repaired? <br /> ivas repair done under inspection?lYes Nol Here"soil samples anaiyxed?lYasl No BTXE TPN-GI TP14-0. Pb/ED8I ' <br /> IType of failure/discharge catastrophic long-term leakage overfill Iunknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Ground Water 50ef/Tear Average Annual PrecipitationlA= 14 .10-25 <br /> Ion-Site Well(s) Yes No Number & Type Irr Dom Pub <br /> S Scare S Scare S Score <br /> :Distance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C. 5 pts <br /> 0 if 0 if O if <br /> R condition R condition R condition <br /> IV. Site Feature - Leaching PotentiaL Analysis E is metE is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet)L5 6-/5 1 >100 51-100 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown I Present <br /> Average Annual Precipitation (inches) XXXX:X <10 9 110-25 xxxxxxx� 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of Leachate (i.e., septic systems, water wells, ponds) None Unknown J! `L-J• Present <br /> Unique site features: Recharge area, coarse soil; nearby wells.. 1 .IAt Least Mare than <br /> xxxxxx Nam q Q one -- one <br /> » <br /> COLUMN TOTALS >TOTAL POINTS 0 I r 1 iJ + i O I= 3 <br /> Samole Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts I 40 pts or <br /> 8 - T1. X E B I T I X E <br /> MAXIMUM ALLOWABLE S-T-X-E LEVELS (PPM) 1 50 50 SO � .3 .3 1. 1. NA\3 <br /> Sample Result:S I'7 GASOLINE inn 100 10 <br /> 3 J �61 <br /> � MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> s s Tpl a o DIESEL 10,000 1000 100 <br /> FOOTNOTES: `'"'if documented soil and/or ground water contamination is present, do not complete the leaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground-water.) <br /> \1 If depth is > 5 ft. and c 25 ft.,!scare 0 points. If depth e.-5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, scare 0 points. <br /> \3 Levels for BTXAE are not applicable at a TPH concentration of 10 'ppm Cgasaline) or 100 ppm (diesel)- <br />, VI. STAFF RECOMMENDATION/CONCLUSION �J-. (��f S Q <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels *Yes No b (/Y�fo <br /> 2. Recommend Site Closure Yes No If Yes, Refer to Site Mitigation for Evaluation i <br /> VII..REVIEW EVALUATION - TO BE COMPLETED BY A 'SUPERVISOR/SENIOR 4- L fP, <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES No IR5FERM TO SITE MITIGATION FOR EVALUATION YES mol <br /> DATE REFERRED / / DATE CLOSURE LET q MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />