Laserfiche WebLink
SA.N )CAcUIM m:,= PUBLIC HEALTH SERVICES/EHVIROHMENTAL HEAL'" DIVISION l `D 3 <br /> WCRKSHEET FOR SITE CLOSURE EVALUATION DAT'c 'D <br /> SLEEPS CODE <br /> NAME OF FACILITY <br /> MFUEL <br /> TANK [0 'J D o�-.L{ l,p 1� <br /> ADDRESS �7 LQ C�k <br /> TANK SI2E 2 K <br /> �lf�eCQ <br /> 1. GENERAL SITE HISTORY ••• <br /> Is permit curren[1 Yes No Penit tl <br /> Facility Status Code Doc.Soil/CJ Cont Yes No <br /> Nurber of Tanks at facility �'' Age of Tenks(If available) Type of Tank Steel FbrgL Sngl Dual <br /> .iOTANIKISTORYFoiled recAMOIII&PO <br /> No If yes, give dates) / / ;? tested4 Yes No X Ppair made t° the tank system?! Yes ) het was repaLred7 P� �� +- �1JG ye- 1 ir done under irepection7 Yes Nples analyzed? Yes X No BTXE X TPH-G .X TPH-Dx- Pb/EDBfailure/discharge catastrophic overfill /( tnknovn ocher: <br /> :'/. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTEMTIAL ANALYSIS) <br /> th to Ground water 4 Ref/Year ; Average Arcual Precipitation A+ 14 10-25 <br /> Sail Sartples Received les � N° Oep D <br /> Cn-Site Well(s) Yes No Nurber L Type Irr Ocm Pub <br /> 5 Score 5 Score S Scare <br /> Distance to wellif <br /> 0 f <br /> s) from Tank ft; ft; ft C Pts Cpts C <br /> O ifO if <br /> R cordtcion R condition R condition <br /> V. site Feature - Leeching Potential Analysis <br /> E is met E is met E is met <br /> 25-50\1 <br /> (Minim Depth to groaadwater from the Soil Saaple (feet) <br /> >100 51-100 <br /> Fractures in subsurface (applies to foothills or mountain areas) <br /> N or'e Unknown Present <br /> Xx <10 9 10-25 xxxxxxx 26-40\2 <br /> Average Arrx:al Precipitation (inches) <br /> Man-Made corajits which increase vertical migration Nttia (� Unknown PresmC <br /> of Leachate (i.e., septic systems, water wells, ponds) I <br /> At least More than <br /> Unitive site features: Recharge area, coarse $OIL, nearby wells. Xxxxxx Mornone one <br /> �5 <br /> COIUlM TOTALS»TOTAL POIN75 • <br /> Sample Result: (3 T X OR E) RANGE Of TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> 3 3 T X E B T X E <br /> MAXIMLM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. MA\3 <br /> GASOLINE 1000 1cO 10 <br /> Saaple Result: 100 <br /> TF'HO ,• V-5o0 MAXIMla4 ALLCWBLE TPH LEYELS (PPM) DIESEL 10,000 1000 <br /> TPx <br /> SOIL andon/or ground water contamination Is present, do not ccaplete the Leaching potential <br /> FOOTNOTES: •••If doaaoented <br /> tys ISOs. (;,e., site is cur FOOTNOTES: on LOT ContaminatiList for soil or grovd water.) <br /> arta <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth «5 ft., do not use table. <br /> \2 if pre°ipitat{on is > 40 inches, score 0 points. <br /> \3 Levels for BTXEE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> ,if. STAFF RECCWENOATICN/CCNCLUSICN <br /> 1. Are 8TX S E or TPH Concentration > Allowable levels *Yes No <br /> X If Yes, Refer to Site Mitigation for E <br /> wluation. RecoTmend Site Ctll;71Y�11on <br /> vit. REVIEW EVALUATICM - TO Be CWLETED BY A SUPERVISOR/SENIOR <br /> CCNCJR WITH STAFF RECL7QLEHDATICM FCR CLOSURE YES NO REFERRED TO SITE MITI WTION FOR EVALWTION TEs NO <br /> OA1E RE FEARED O / 2 <br /> / - DATE CLOSURE LETTER MAILED <br /> NAME OF ��J <br /> EVALUATOR <br /> -eH 23 80 (UGTWKSHT)\5/90 <br />