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SAN JCACUIX CO PUBLIC HEALTH SERVICES/ NVIRONMENTAL HE:AL1 VISION DATE 7—"26—o <br /> VCRXSHEET FOR SIIE"LLOSUR£ EVALUATICH <br /> STEEPS CODE <br /> NAME OF FACILITY <br /> (J p TANK ID � —A <br /> �j' <br /> ADDRESS <br /> TANK SIZE So cc, FUEL TYPE L( <br /> npo <br /> I. GENERAL SITE HISTORY <br /> � <br /> �ZCZ3/��,d Facility Status Code Doc.Soil/CJ <br /> Cont Ye No <br /> Is permit current? Yes No Permit I <br /> Age of Tanks(if available) rb �� Type of Tank Steel Fbr Sngl Dual <br /> Number of Tanks at facility <br /> :II. TANK HISTORY <br /> Vas Lank tested? Yes No Failed precision test 7 Yes No if yes, give dates) <br /> iWas a repair made to the tank sys <br /> telt Yes N If yes, khat was repaired? <br /> Was repair done under inspection? Yes <br /> No Were sail sraples analyzed? a No 3T7i✓ TPH TPH- - Pb/EDB <br /> ng-Cera leakage overfill ��+� other: <br /> Type of failure/discharge catastrophic lo <br /> I`J. REMOVAL HISTORY (ATTACH tNSPECTICir REPORT FOR SITE OE1Afl5/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) . <br /> Grand <br /> Vater Lk Ref/Year <br /> Soil Samples Receiv Yes No Depth to GrAverage Annual Precipitnticn 0.= 14 10-25 <br /> On-Site Wells) No NL,mber L Type Irr Dom Pub S Score S Score S Score <br /> wI .�+ ft C 10 pts C 9 pts C 5 pts <br /> if <br /> Distance to Vett(s) from Tank ft:� 0 if 0 if _ 0 c <br /> anditicn <br /> R coition R condition R c <br /> condition <br /> E is mxt E is met E is met <br /> V. Site Feature - Leaching Potential Analysis >100 Cl <br /> 51-100 25-50\1 <br /> H or,(M 11 inimum Depth to gro�sxiWater from the Soil Sample (Etat) >100 <br /> Unknown Present <br /> Fractures in subsurface (applies to foothills or mocntain areas) <br /> • yxxx <10 9 10-25: xxxxxxx 26-40\2 <br /> Average Annual Precipitation (Inches) <br /> Man-Made ccrp4uits which increase vertical aigration None UrkrKA-n Present <br /> of leachate (i.e., septic syste=, water veils, pow' ) <br /> At least More than <br /> ' 0f5e <br /> Unique site features: Recharge area, coarse soil, nearby wells. Xxxxxx H one We <br /> COLUMN TOTALq»TOTAL POINTS 40 is or less <br /> Sacple Result: (3 T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts P <br /> 3 T Xf E B T X E HA\3 <br /> WI" ALLCWABLE 3-T-X-E LEVELS (PPM) 1 50 50 50 .3 ; .3 1. i. <br /> GASOI I HE 1000 100 ,I i 4: 10 <br /> Sarple Result: 1000 100 <br /> MAXIML?1 kLLOJZL TPH LEVELS (PPM) DIESEL t0,000 <br /> :J4• 1,C) CdC I�TPH <br /> —If documented soil yd/or grand water contamination Is pr111 esent, do not complete the leaching potential <br /> FOOTNOTES: is, (i.e., site is currently on UGT Contamination List for soil or gra water.) <br /> analysis- 0 points. If depth —5 ft., do not use table. <br /> \1 If depth is > 5 ft. and < 25 'ft., score nts, <br /> \2 If precipitation is > 40 inches, score 0 po <br /> \3 Levels for BTXbnc <br /> E are not applicable at a TPH coentraticci if 10 ppm (4 asoline) or 100 ppm (diesel). <br /> VI. STAFF REC0MMENOATICN/CCNCLUSICN <br /> 1. Are 87X b E or TPH Cox entratiarts > Allowable levels 'Yes No <br /> 2. Recommend Site Closure Yes No <br /> if yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW! EVALUATION - TO 3E COMPLETED 3Y A SUPERVISOR/SENIOR <br /> CCNCJR WITH STAFF RECcmKENDATICx FCR CLOSURE YES NO REFERRED TO SITE MITIGATION FCIt EVALUATION YES NO <br /> DATE CLOSURE LETTER MAILED <br /> DATE REFERRED <br /> NAME OF <br /> EVALUATCR <br /> EH 23 d0 (UGTWKSHT)\5/90 <br />