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SAN :QAs7U1H (CUNT 7LfC HEALTH S-RVtCES/E4VIRCNMENT(C HEALTH 0 'ION <br /> t. UGS XSHEET FCR st iE CLOSURE EVALUAT ICN <br /> AME OF FACILITY / EPS CCOE 3L� <br /> [IYANK ID x <br /> fANX SIZE I 1pK L TYPE (J(, 02 = !oK <br /> It. GENERAL SITE HISTORY <br /> Is permit currencT es o ermic j IFaeility Status Code oe.Soi(/GV Cone es o <br /> tsnber of tanks at faeitity 2—, ge of ranks(if available) IType of tank tee( IxFbcgt ngl Dual <br /> fit. TANK HISTCRY <br /> as tank tested? es o ailed preeisien test T es o If yes, give date(s) <br /> ss a repair made to the tank system? ` es No f yes, what was repaired? <br /> ,as repair done under inspection? I es l o dere soil samples analy%ed7l es o TXE PH-Gf PH-0 b/E08 <br /> ype of failure/discharge atastrophie long-cern leakage ' verfill ! own cher: <br /> iV REtlOVAL tSTORY (ATTACH INSPECTION REPORT FCR SITE OETAILS/CCLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> pit Samotes Received fifes x �Io epth to Grouid 'later 3S et/YearI ��Average Annual Precipitation _ [4 0-25 <br /> -Site 'Jetl(s) es I �Jo unber 3 Typel Irr �om p.�b <br /> S Scare S core S core <br /> iscance to Well(s) from Tank ft; ft, ft C 10 pts C pts C pts <br /> 0 if 0 if 0 [ <br /> R ondition R ondition R ondition <br /> i . Site feature - Leaching Potential Analysis E �s met E is met s met <br /> linimum Oepch to grow-dwacer from the Soil Sampte (feet) 35(Z Z3 I >t00 1-100 <br /> r:3ctures in subsurface (applies to foothills or motncain areas) C) None I Unknorn present <br /> average Annual Precipitation (inches) xxx=x I oo 9 J 10-25 �XxXxxx M25-40\2 <br /> man-made conduits 4ic.4 increase vertical migration Q <br /> �f leachate (i.e., septic systems, water wells, ponds) ( None I ( Unknown resent <br /> igse site features: Recharge area, coarse soil, nearby welts. 7 ( At Least i ore than <br /> xxxxxx None one one <br /> CCLUMN TOTALS»>TOTAL POINTS U 7.7 I L 3 <br /> ample ResuLt: (3 T X OR E) RANGE OF TOTAL POINTS 9 pts or more I 41 - 48 pts GO pts or ess <br />` B r '5'0 <br /> E B T X E <br /> MAXIMLM ALLCLIABLE 3-r-X-E LEVELS (PPM) 1 50 50 50 .3 (.3 1. 1. ( NA\3 <br /> rill <br /> e Result: SCLINE 1000 100 10 <br /> -9-p IM.7I ALLCUABLE TPH LEVELS (PPM) <br /> / 7TPH (ESEL 10,000 I 1000 100 <br /> COINOTES: ---If docunenced snit 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., core posnc If depth < 5 ft., do not use cable. <br /> \2 If precipitation is > 40 inches, score posits. <br /> \3 Levels for 3TXbE are not applicable at a TPH concentration of 10 ppm (gasoline) or t00 rpm (diesel). <br /> STAFF RECCMENOATION/CCNCLUStON <br /> 1. Are 3TX b. E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Reccmnend Site Closure Iles o If Yes, Refer to Site Mitigation for Evaluation <br /> I. REVIEW EVALUATION - TO 3E CCHPLETED 3Y A SWERVISCR/SENIOR <br /> OHL-UR VITH STAFF RECCMMENDATION FOR CLOSURE ES �JO E:'cRRED TO SITE MITIGATION FOR EVALUAitCN RES ( 0 <br /> ATE REFERRED ATE CLOSURE LETTER WILED f / <br /> JAK OF <br /> :VALUATOR <br /> V ALUATOR <br /> EH 23 30 (UGTVYSHT)\5/90 <br />