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05/28/2004 12: 58 2094683433 FIFTH FLOOR PAGE 01 <br /> ' SAN J=Ut NTT MEC VEALTH SERVICES/ESV1RcNMEXTAL H D IVI SIO)1 <br /> GST V=SHEET FOR SITE CLosuRE EVALUAT(C)! DATE O <br /> NAME OF FACILITY •� <br /> In U,u Y k f4As'} ��5 f/l C.i —5 D SWEEPS CODE <br /> AOORESS <br /> Sv 1kL ZC TAgY. IO 0 - <br /> TANK SIZE FUEL TYPE / <br /> ' I. GENERAL SITE HISTORY 'lT <br /> YY1 <br /> Is permit current? Yes Nv Permit :If - Facility statL= code Doc.Soil/GV Cont YesRo <br /> Hurber of tanks at facility Aga of Tankz0 f available) type of Tank Steel Fbrgl 5ngl De_L <br /> ;El, TAUT HISTORY <br /> IVas Tank testedz Yes No Falled precision teat 7 Yes No If yrs, give date(s) <br /> ' lWas a repair mode to the tank syst=? Tea: No 11 yes, what was repaired? <br /> Vas repair done under Irtpectian7 Yd No Vere soil samples anelyzed7 Yrs NoBTXE TPH-G TPH-D <br /> ' Type of failure/discharge catastrophic long-term leakage overfill un[natin other: <br /> IY. RF-40VAL HISTORY. (Il7TACH INS?ECTLCU RE?CAT FOR SITE DETAILS/C•CLLECT DATA FOR LEACHING P-OTEATIAL AXXLYSIS) <br /> ' -Soil Samples ReceivedI.Yes Ho Depth to Grand Vater Ref/Year .Average Arcual Precipitation A� 14 10-25 <br /> 11 On-Site WeLI(s) Tea No }lumber i Type Irr 04= Pub <br /> S Score S Score S Score <br /> Distance to <br /> we"", <br /> frac Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if O if 0 if <br /> R ccrditIon R condition R_ dondition <br /> V. Site Feature - Leaching Potential Arvlysis E is ¢yet E is met E is met <br /> ' Minimum Depth to grvz-dwater frac Che Soil Saaple (feet) X100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mxsntain areas) }lone Q Unknown Present <br /> Average AorL,.l Precipitation (arches) XXXXXX <10 9 10-25 xxxxxxx Z6-40%Z <br /> ' Han-Hado carm6uits which increase vertical migration <br /> of Leachate (a.e., septic systems, water wells, pads) Hone I Llr� Present <br /> ' <br /> Unique site features: Recharge area, coarse soli, nearby wells. �— II At least More than <br /> on <br /> mo_. l one <br /> I <br /> COLLM TOTAL 9»TOTAL PAINTS + 31 i 5 l <br /> ' Saaple Result• (6 T X OR E) RANGE OF TOTAL POINTS 49 pts ar ire 41 - 48 pts 40 pts or less <br /> I T X E B T X E <br /> HAXII�t�1 .ILLCtUHLE I-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA13 <br /> ' Seaple Result: GASOLINE 1000 100 10 <br /> MAXI" ALLCWSLE TPH LEVELS (PPM) <br /> TPR DIESEL 10,000 1000 100 <br /> ' FCOT40TES: —If documented soil arWar grourd water eontaairtatlon as pros ant, do not cemplete the leaching potential <br /> analysis. (i.e., site is currently on UGT Contunination List for soil or groLr,4 water.) <br /> %l if depth is > 5 ft. and < 25 ft., score 0 points. If depth —5 ft., do not Use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levals for M&E are rot applicable at a TPH concentration of 10 ppm Cgesoline) or 100 ppm (daeseL). <br /> ' VI. STAFF RECCMMEHOATICXICONCLUSICN <br /> 1- Are BTX & E or TPH ConcenttaLiora > Allowable Levels 'Yes No <br /> 2. Recomaurr3 Site Closure Yes Ko if Yes. Refer to <br /> Site Mit[gatipc� for Evaluation <br /> VII. REVIEW EVALUATICX - TO BE CWLETEO BY A SUPERVISOR/SENIOR <br /> ' CCNC•JR WITH STIFF zECO"(F_14OATICH FCR CLOSURE TE 5 NO REFERRED TQ SITE MITIGATION FOR EVALUATIN YES HO <br /> DATE REFERRED / / DATE CLOSE LETTER )LAILED / / <br /> ' HANE OF <br /> EVALUATCR <br /> EH 23 80 (UCTWXSHT)\5/90 <br /> 05/28/2004 FRI 13: 52 [TX/RX NO 56311 [x]001 <br />