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SAN JCAOUIH Cal 'UBLIC HEALTH Sc-RVICES/ENVIRCNMEHTAL HEAL;' `fIS-ION <br /> } CRXSHE£T FOR SITE CLOSURE EVALVATIOR EAE <br /> vAME: C, FAC:LITY h <br /> :E_Ps cooE O 6 <br /> A00RESS Axz 0 .1 i <br /> (O�j <br /> "[AMC SIZE + UEL TYP£ <br /> GBNSU L SfTE HISTORY <br /> ff <br /> Is permit current? as o ermit 9 1,P0 acility Status CodeE oe.Soil/Gv Cont as o <br /> ivxvr of Tanks at facility ge of Tanks(if avaitabte) (' type of Iank teal Pbr9t ngl x vol <br /> I. TANK HISTCRT <br /> .las Tank tested7 6s0ailed precision test 7 es a If yes, give dates)1 101 <br /> .:as a repair made to the tank system? es 1 Na f yes, what was repaired? /v <br /> .ms repair done wider inspection? 4es ,�/��ra ere soil samples analyzed? as 0 TX E.! , P►t-r& yTPH-0 I 'b5/EOS <br /> yFe of failure/discharge Oratastrophie long-term Leakage verfill sown 1 10cher: i <br /> ASMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samptes Received as al epth to Crowd 'later of/Year S �� verage Annual Precipitation 14 0-25 <br /> 7n-Site well 3) as , o ur+ber S Type irr <br /> S core S Score S core <br /> aistance to Vett(s) from Tank ft; ft; ft C 0 pts C 9 pts C pts <br /> 0 f 0 if 0 f <br /> R enditfon R onditian R ondition <br /> 1. Site Feature - Leaching Potential Analysis E is met E is.-met E s met <br /> linin-m Depth to groundwater from the Soil Sample tfeet) .�i X100 I 1-100 ( 25-50\1 <br /> :ractures in subsurface (applies to foothills or mountain areas) None I Unknown resent <br /> ,vcrage Annual Precipitation (inches) ( <10 ! 9 10-25 xxxxxxx 26-40\2 <br /> 'an-Made conduits uhich increase vertical migration i <br /> .F teacha-.e (i.e., septic systems, water welts, ponds) /0 Hone � Unknown resent <br /> nique site features: Recharge area, coarse sail, nearby wells. ( At leastI 4ore than <br /> xxxxxx None one 11 one <br /> �L g It97 <br /> � -39 <br /> p�LCCOL" TOTALS»>IOTAL POINTS 20 * - 3 O <br /> :amole Result: (B T X OR E) RAHCc OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pis or Less <br /> B T X E � B T X E <br /> J'"f�k MAXIMALLCUAStE B-T-X-E LEVELS (PPM) 1 SO 50 50 .3 .3 1. 1. NA\3 <br /> :ample Result: OLINE 1000 100 10 <br /> W M <br /> AXIM ALLOWABLE TPH LEVELS (PPM) <br /> 5dPg Yr3. IESEL 10,000 1000 100 <br /> COTNOTES: *,*If docunenced 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 < 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 BTXLE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> STAFF RECC-HENOATICN/CCNCLUSION <br /> I. are BTX i E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure Pas oAIrIf Yes, Refer to Site Mitigation for 'evaluation <br /> REVIEW EVALVATICN - TO BE CCMPLETED BY A SUPERVISOR/SENICR <br /> tCNG+R WITH STAFF RECCHHENDATICN FOR CLOSURE ES 6 £FEAREO TO SITE HITIGATICN FOR EVALUATION �E4 0 <br /> bAIE ISFERRED / / ATE CLOSURE LETTER MAILED f / <br /> iiArE OF <br /> •:VALUATOR I <br /> _H 21 10 (UG::'YSHT)\5/90 <br />