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SM JOAQI IM C PML I C HEALTH SERV I CE S/E-YVI ROD1EITAL HEAL i i 'VISION <br /> HE--T FOR SITE --=aE EVALUATION DATE <br /> NAME FACiLIT ( /S H J O� �G� �SWE_..S CODE( /O 3� <br /> woRF..,:! ITAKK ID s) <br /> TAXK SIZ`1 �� y G�`� I FUEL TYPE+ <br /> II. GE.KUL SITE HISTORY <br /> Is p"it current?IYes I !No I Permit t� - (Facility Status Code!j Z_ (Doc i( Cont'Yes l '-�ol <br /> IHsmtx,r of Tanks at facility, (Age of Tanks(if available)( (Type of TankiSteel) l Sngl) Dual) <br /> lIt. TAU HISTORY <br /> Stas 1't nit tested? Yesl No Failed precision :est 7iYesl No 11f yes, give date-(S)I / <br /> ;Vas epair made to the :ank system?lYesl Vol If yes, what was repaired?) <br /> Yas <br /> cpaair done nder irsoec;ion7IYes l No Were soil samples analyzedlIYes I IMoj 3TXEI ITPH-GI 1-,?4-01 1P'o/-3I <br /> Ty' 'of failure/dischargel Icatastrophic! Ilona-cera Leakage IoverfiLLI I untrianl lather: <br /> IV. M147VAL HISTORY (ATTACH IMSPECTICN REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHIXG ?C-1E*TIAL ANALYSIS) <br /> Saiun <br /> I Samptes ReceivedlYesl IMoI IDepch to around Yater � ag <br /> Ref/year Q (Avere Ann=ual PrecipitationlA--I1G 110- <br /> Site Welt(s)IYes IMoI✓ Number S Type) IIrr (Dom I?uh+ <br /> S Score S Score S Score <br /> �—E_ :e to Yelt(s) free Tank f:; ft; ft C 10 pts C 9 pts C 5 pcs <br /> L— 0 if 0 if I 0 if <br /> R condition R condition R condition <br /> .e Feature - Leaching Potential Analysis E is net ° is met I E is met <br /> Depth :o grouncNoter from the Soil Sa®le (feet) �' / �, I >100 I 151-100 I C 125-5C\l <br /> Fr- <br /> °-r--s in subsurface (applies :o foothills or mountain areas) I Mone I I Unknown I (Present <br /> Average Annual Precipitation (inches) rocs <10 I 9 1 10-25 1===l 26-40V <br /> Mss, hce conduits which incre-ase vertical migration <br /> of �-ate (i.e., septic systems, water wells, ponds) I Nom ( I Unkrrown (Present <br /> site feat-a--s: Recharge area, zoarse soil, nearby wells. I Mone I I At teastj More than <br /> one am <br /> =L'" TOTALS>—TOTAL MINTS e I + ( 3(i I l.' I= 3 b <br /> Sat a Result: (3 T X Cit E) RANG% CE TOTAL POINTS 69 pts or =ore I 41 - 48 pts 40 pts or less <br /> MAXIMLM AL.L0W4LE 3-T-X-E LEVELS (PPM) 11 <br /> 501 501 50 I .3 I <br /> .3 11.1 T. ( MA\3 <br /> �Si-- a tesult: 3LGASOI.IME 1000 I 100 i. i ,D <br /> MAXI" ALLOWAE ,A LEVELS (PPM) <br /> 2/2m TPH DIESEL 10,000 1 1000 100 i <br /> FOU10IMS: —if do=snented soil and/or grand water contamination is present, do not complete :he lea=s ential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or grand water.) <br /> \1 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 Levels for 3TXEE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VT. AFF 2ECOMKEDATIOM/CCNCLUSIOM j <br /> F <br /> . Are 3TX b E or TPH Concentrations > Allowable Levels *Yes) No <br /> Recom=end Site CtosureIYes I INoI 1-If Tes, Refer to Site Mitigation for Evaluation <br /> VII, -r!EY EVALUATION - TO 3E CONPt—ETF7.3 3T A S1JPEZVISCR/SEMIOR <br /> fid WITH STAFF RECOWENDATICM FOR : EITESI IMO (REFERRED TO SITE MITIGATION FOR EVALUATIONITESI IMO <br /> CATE REFERRED( (DATE CL=JRE LETTER MAILED I <br /> KV E OF <br /> kVALUATOR <br /> EH Z3 30 (UGTYKSHT)\5/90 <br />