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SAN JCACUIX CC PUBLIC HEALTH SERVICESPFNVIRONMENTAL HEALI VISION DATE <br /> Ui„ CRX <br /> ( VSHEET FCR StTCCLOSURE EVALUATION <br /> SVEEPS CODE <br /> NAME OF FACILITY r� �+ <br /> /,, TANK ID 2 /� Q�Q� <br /> SSG' <br /> ADDRESS L 3/5— � j <br /> TANK SIZE S 0,20 FUEL TYPE <br /> I. GENERAL SITE HISTORY •tri <br /> U.'7 ) V Facility Status Code p( Doc.Soil/CJ Comet Yes No <br /> Is Permit current7• Yes No Peron L / <br /> Number of Tanks at facility <br /> Age of Tanks(if available) JD Type of Sank Steel hr <br /> Sngl Dua <br /> gt' l <br /> I[. TANK HISTORY / <br /> es No Failed precision test 7 Yes No If yes, give date s) <br /> Vas Tank tested? Y / ! , <br /> I F_ <br /> iWas a repair made to the tank sys <br /> tell Yes ' No If yes, what was repaired? <br /> was repair done under irlspec <br /> tion? Tei No were soil sraples analyz Ye No 8TX TPH- TPH- - Pb/E09 <br /> Type of failure/discharge catestrophic long-term leakage overfill tnktwwn other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTICM REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Ref/Year ;,V-7 Average Armal Precipitation A- 14 10-25 <br /> Soil Samples Receiv es No Depth to Grourd Vater �� <br /> Miner L Type S Score S Score <br /> On-Site Vell(s) No Irr Dom Ppb S Score C 9 pts C 5 pts <br /> ft C 10 pts <br /> Distance to Wells) from Tank t. t; if _ 0 if <br /> R ccrdition R cordition R condition <br /> E is met E is met E is met <br /> rtu <br /> V. Site Feature - Leaching Potential Analysis C is met 25-50\1 <br /> ),100 <br /> INinia Depth to 9roLsxiwater from the Soil Sample (feet) 17UnkrAwn Present <br /> Hort <br /> Fractures in subsurface (applies to foothills or gxntain areas) 26-40\2 <br /> • - Y Xxxx�cx <10 9 10-25. xxxxxxx <br /> Average Arnual Precipitation (inches) <br /> Nan-Mede conduits which increase vertical migration None UnknrKati Present <br /> of leachate (i.e., septic systems, water wells, pow' ) <br /> CI <br /> At least More than <br /> Unique site features: Recharge area, coarse soil, nearby wells. xxxxxx None _I orle ore <br /> S + s Vl <br /> COLUMN TOTALS»),TOTAL POINTS 40 is or less <br /> Sample Result: (8 T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts P <br /> B TX E B T X E <br /> KA <br /> ell Z,& MAxIM?� ALLWA9LE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. \3 <br /> GASOLINE 1000 100 10 <br /> Saaple Result: <br /> MAXIM.01 ALLOWABLE TPH LEVELS (PPM) 1000 100DIESEL 10,000 <br /> Q QCZ} n /✓C TPH-If documented tm:ial <br /> soft and/or ground water contamination is present, do not complete the leaching po <br /> FOOTNOTES: analysis. (i.e.,Isite is currently on UGT Contamsimtion List for sail or grourd water.) <br /> ints. If depth —5 ft., da not use table. <br /> \1 If depth is > 5 ft. and < ZS ft., score 0 P?ncs. <br /> \2 If precipitatasoline) or 100 ppm (diesel). <br /> ion is > 40 inches, scoro 0 F''o <br /> \3 Levels for STUE are not applicable at a iPH concentration of 10 ppm C4 <br /> VI. STAFF RECCCmMENDATICN/CONCLUSICM <br /> 1. Are BTX b E or TPH Concentrations > At levels 'Yes No <br /> 2. Re•cammerd Site Closure Yes Na <br /> If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE CWLETED BY A SUPERVISCR/SENICR <br /> CCNCJR WITH STAFF RECgtKENDAT1Cti FCR CLOSURE YES NO REFERRED TO SITE MITIGATION FOA EVALUATION YES NO <br /> DATE CLOVIR= LETTER MAILED ! ! <br /> OATS REFERRED ! / <br /> NAVE OF <br /> EVALUATOR <br /> EH 23 80 (UGTVKSHT)\5/90 <br />