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SAN 4CACUIN = '?nSLIC HEALTH SERVICES/ENVi ONMENTAL HEAL'IISION <br /> ' Uj_,,wCRZSHEET FOR SITE CLOSURE EVALUATION �' DATE <br /> . St1EEP5 CCOE i <br /> MAIMS OF FACILITY <br /> ADDRESS 1D33 w C.VI�'� �''r 'WS-ttit.k_-FVrq g5w(o TANK ID # <br /> TANK SIZEI FUEL TYPE l )1.Zp� dY� -z>a V'q 1� <br /> 1. GENERAL SITE HISTORY J "i +*+ <br /> Faci ity status Code Doc.Sail/GV Cont Yes No <br /> Is permit current? Yes No Permit � O( <br /> Nurber of Tanks at facility Age of Tenks(if available) Type of Tank Steel Fbrgl Sngl Dual <br /> .It. TANK HISTORY <br /> W as Tank tested? Yes Na Failed precision test 7 Yes No If yes, give date(s) <br /> Was a repair made to the tank systems Yes No If yes, what was r i red? [, ti 1 Ir-s*`i rt✓ lard f d41c� <br /> Was repair done under inspection? Yes ✓No Were so{l saaples anal ed7 YesLwn' TPH-G TP - Pb/EDB <br /> Type of faiEure/discharge catastrophic [org-teria leakage lover ll <br /> REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SIIE DETAILS/COLLECT DA A FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes / No Depth to Grouxid Vater DFe Ref/Yea pr+r ;olj Average Annual Precipitation A= 14 10.25 <br /> Cn-S{te Vell(s} Yes No Number L Type Irr Dom pub <br /> S Score s Score S Score <br /> Distance to Vell(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R condition R condition R cord!tion <br /> Y. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> IMinimua Depth to groardwater from the Sail Sample (feet) <br /> >100 51-100 1 & 1 ?5.50\1 <br /> Fractures in subsurface (applies to foothills or, mountain areas) <br /> Nave UnkrAun Present <br /> <10 9 10-25 xxxxxxx 26-402 <br /> Average Annual Precipitation (inches) xxx�ux <br /> Man-made conduits which increase vertical migration None "=.nPesen <br /> rt <br /> of leachate (i.e., septic syste=, water wells, ponds) <br /> At least More than <br /> Unique site features: Recharge area, coarse soil, nearby wells. xxxxxx wax one one <br /> ; ; <br /> COLUMN >> POINTS ✓�s a <br /> Sample Result: C3 T X OR E) RANGE OF TOTAL POINT 49 pts or more 41 - 48 pts 40 pts or less <br /> B T X E B T X E: <br /> NAS <br /> !` KAXI�I ALLOWABLE 3-T-X-E LEVELS (PPM) 1 50 50 50 .11 .3 1. 1. <br /> 2r� F7- <br /> 15SEL <br /> ESample Result: � �t5IIAXINL71 ALLOWABLE TPH LEVELS CPPV)j z TPH <br /> 10,000 1000 100 <br /> FOOTNOTES: —If documented sail andlor ground water contamination is present, do not complete the leaching potential <br /> analysis, (i.e., site is currently on UGT Contamination List for sail or ground water.) <br /> \1 If depth is > 5 ft. and < 25 ft., scare 0 points If depth «5 ft., do not use table. <br /> \2 if precipitation is > 40 inches, scare 0 points. <br /> \3 Levels for BTXbE are not applicable at a TPN c entration of 10 ppm (gasoline) or 100 ppm Cd{esel). <br /> VI. STAFF RECOWZ4DATION/CCNCLUSICN <br /> 1. Are BTX S E or TPH Comentrations > Allowable Levels 'Yes <br /> 2. Recommend S{te Clasura Tes No If yes, Refer to Site jitigation for Evaluation <br /> vii. aSVIEV EVALUATION - TO SE COMPLETED By A SUPERVISOR/SENICR <br /> CCNu:'!R WITH STAFF RECOO(ENDAIICN FCR CLC$Un TES NO REF TO SITE MITIGATION FOR EVALUATION YES NO <br /> OATS 2EFERREO DAT CLOSURE LETTER IL <br /> MAKE OF <br /> E'fALUATCR <br /> EN 23 ao CUGTVY,SHTi\5/90 <br />