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SAN 1CACUtR CCt KISLIC HEALTH SERVTC=S/EHVTZCHNENTAL HEAL, (Cti <br /> ' f*S <br /> (• uu�YF XUSHEET FCR SITE CL=RE EVALUATICH - 1.+' OATE``I <br /> INANE OF FACILITY I Z�Atlt I SVEE?S CSE I ( <br /> IAOOR£SSI .4`3iS �V0.�W ICO `l (TANK (D %I <br /> TANK S(Z. FUEL TYP£ SAD�L�D <br /> It. GENERAL SITE AIS'T&T <br /> Is permit current?IYesix INoI Permit fl '��D lFaeilirf Status Cadair l0a.SoiL/G.1 C:ntlTo$ Hol <br /> Hunter of Tanks at faeiLityl ZS Age of Tankz(if available=30IType of TanklSteell1,' Fbryl lSngl! Dual <br /> (Ii. TANK HISTORY <br /> Vas Tank tested?I'fez IINoI !Failed precision :est 7IYes !Hol d, IIf yes, give dace(s)I // / <br /> !Was a repair made :o the tank sys m?!Yes I No I If yes, resat was repai red ? T>r_.. ,+ _P'1 ' adds�lo+;yo <br /> Vas ,repair done wider inspection? Tes INoI �IWere soil samples analyzed7lTesl INoI STXEI (TPN-GI ITPY-OI IPb/E]8l <br /> Type of failure/dtschargel IcstastrcO icl !long-Cara Leakage! averfilll i lac other: I <br /> (V. REtCVAL HISTCRT (ATTACS INSPECTICM ZEPCRT FCR SITE OETAILS/CILLECT DATA FCR LEAMING POTENTIAL ANALTSIS) <br /> Soil Samples Received Yesl (Nol IDepta Co Ground Vater! Ref/year !Average Annual Preeipitat ionlAsll4 Ila-25 <br /> IOn-Site 'lell(s)IYes! IMCI.,/ lH mber L Typal IlrrI IOam+ 1p-�bl <br /> S Score S Sear_ S Scare <br /> IOistanc: to Vell(s) from Tank! ft; ft; ft C 113 pts C 9 pts C 5 pts <br /> 0 if 0 if O if <br /> R <br /> condi Cion R card i t i on Z ccadi t i cn <br /> V. Site Featur. - Leaching Potential Analysis E is met ! e is Met is net <br /> !minimum Oepth :a groundwater from :he Soil Sample (feet) I >100 I I51-100 I S ! s-50\1 <br /> !Frac::fres in ssi:surfaea (applies to foothills or =untain areas) I I Nan* I I Unkrso. I (Present <br /> !Average Annual Precipitation (inches) xxcaxl ,I0 I 9 110-zs Ixxx>= za- 012 <br /> lNan-!lace conduits which increase vertiat migration (� <br /> of Leachate (I.e.. septic systems, water veils, porn`s) (lNone Urk.-sotirs Present <br /> (Unique site features: Recharge area, :arse soil, nearby wells. N ` G,onej I At le � !Noce than <br /> om <br /> =I.UM TOTALp»TOTAL POINTS I <br /> Sampla Result: (3 T X CR E) ZANG2 Of TOTAL POINTS 49 pts or mare I »i - 4,3 pts ! 40 pts or less <br /> CJ�tg 2.�iC7 NAXINl91 ALLCWSL? 3VH <br /> 3-r-X-c LLS (PM t` .4 5(1i 50 I -3I.3 I 1.I 1. ` NA\3 <br /> Sample Result: IGASCLIXE 1000 I 100 l 10 <br /> NAXINL71 ALLWSLE TPN LEVELS (M) <br /> I�O TPN DIESEL 10,000 1 1000 ! lea <br /> FCATNOTES: —If doesmented sail a or- groeu+d water cantanination is present, do not cadets the Lescsinq potential <br /> analysis. (%*., site is currently on UG-6 Contamination LisC for soil or ground -dater.) <br /> \1 (f depth is > 5 ft. and < 25 ft., scar* 0 points. If depth -Mi ft-, do not use table. <br /> \2 if precipitation is > :0 inches, scare 0 points. <br /> \3 Laveis for 3TXZE ars not appiicsble at a TPN concentration of TO ppm (3asotin*) or 100 :XM (dteael)- <br /> Vt. STAFF REATICII/CLIC-fSSICX <br /> lT. Are 3TX b S or TPR Canentntioss > Altowacte Lmis !'yes! Imo! <br /> Z. Recanmend Sita C.osure{TeslVJ'-'[N04' �If Yes, Zefer :o Site Mitigation for =valuation' <br /> VII. ISVIEN EVALUATICM - TO 3E CWLZ°Tc'7i 3T A SL'PEZVIS"Icst <br /> C_VCR 'AITN i,.LFF .2E'"..?'4¢VDAT:C1i CR CLC•S[tRE�YES iM°I IRFFz'ZRJ TG SI—.c NITIG.tTIC71 FCR :vALUATTCsii7ESi No! <br /> OAT-c 2E-RRE0 / U / (DATE "--'ME 'L=EA XAILMI / / <br /> !HANE ::F <br /> r c IAL'UATCR f <br /> :H `3 20 (::GT'»•XSHT)\5/90 <br />