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SAN XACUIN CCU'NTY IC HEALTH SERVICES/EVVIRCHMENTAL HEALTH 0 ON <br /> UGST ,,.,.(SHEET FOR SiTE CLOSURE EVAUJATICM ATE <br /> 1D� <br /> FACILITY I I Q r� CA ;E S (CCE 1 <br /> y O 1 <br /> a£ss1Y(0 m a.rcacLr0 ANK ID . <br /> ANK SIZEI t0i (,(DC) UEL TYPE le d <br /> GEYERAL SITE HISTORY <br /> is permit current7 es o ermit 4 acility Status Code V I oc.S it/GW Cont es <br /> it <br /> Nurcv r of Tanks at facility 3 ge of Tanks(if available) Iq r ype of lank feel �Fbrgl ngl Dual <br /> I. TANK HISTCRY <br /> Lrns sank tested7 es I o ailed precision test es o V If yes, give date(s) <br /> ;as a repair .made to the tank system? 1Yes Vo 1 vl�f yes, what was repaire0 <br /> as repair done under inspection? 11esere soil samples analyzed? es o 1, <br /> TXE PH-G IPH-0 b/ED8 <br /> i <br /> ;Type of failure/discharge atastrophic long term leakage verfill nknown cher: <br />'�. RE"OVAL HISTORY (ATTACH INSPECTION REPCRT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> >oiI Samples Received I es o epth to Ground Watery of/Year 1Y ; �r,�, verage Arnual Precipitation = � 4 0-25 <br /> ::i Site tlell(s) es o umber b Type I Irr cm ub <br /> S core S core UL <br /> Distance to Veils) from Tank ft; ft; ft C 0 pts C Pts <br /> 0 if 0 if <br /> R onditicn R mditionon <br /> Site Feature - Leaching Potential Analysis EE is met E is :met yinimtm oecth to grcu:rdwater from the Soil Sample (feet) �p >100 1-iCO 25-50\1 <br /> Iractur-s in subsurface (applies to foothills or motrntain areas) ( None Unknown resent <br /> verage Annual Precipitation (inches) xxxxx <10 9 10-25 xxxxxx 25-40\2 <br /> `tan-.Hade cor4jits which increase vertical migration <br /> hof leachate (i.e., septic systems, water wells, ponds) None I Unknown resent <br /> ;nique site features: Recharge area, coarse soil, nearby wells. 7 <br /> I At leascl are than <br /> �x-uxoce one I one <br /> -7COLUMN TOTALS»>TOTAL POINTS * I + <br /> Sample Result: (3 T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or less <br /> B 1 i X E B JT X E <br /> i <br /> MAXIMLH ALLCt1ASLE 3-T-X-E LEVELS (PPM) 1 50 I50 I50 .3 .3 1. 1. I 14A\3 <br /> 100 10 <br /> • <br /> 'amQle Result ASCLINE 1000 AXIMUM ALLOVABLE TPH LEVELS (PPM) <br /> TPH IES"EL I 10,000 1000 100 <br /> '; do not complete the leaching potential <br /> OTNOTES: " I f documented soil and/or ground water contamination is present, <br /> enolysis. (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 3TX3E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ,fin (diesel). <br /> STAFF RECCWENOATICN/CONCLUSICN -O <br /> —B _ � .SPFyr' t:` qr� <br /> 1. Are 3TX £ E or TPH Concentrations > ALLowab(e Levels Yes 1 0 / <br /> // Pp') I-717r' <br /> + 2. Recoruierd Site Closure es o If Yes, Refer to Site Mitigation for _valuation3ym pe, <br /> PPS' �7oo�ri, <br /> 1. REVIEW c/ALUATICN - TO BE COMPLETED 3Y A SUPE.RViSCR/SEN,CR <br /> CNCR WITH STAFF RECCNHENDAiICN FCR CLOSURE SES I�l0 I EFERREO i0 SITE MITIGATION FCR E`/ALUATiCN �(£S 0 <br /> )ATE REFERRED �y pATE CLOSURE LETTER ~AILED f / <br /> CF ' <br /> C;t 23 20 (UGT';KSAT)\5/90 <br />