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SAN XACUIN C: PUBLIC HEALTH SERVIC3/ERVIRCUMENTAL HEAL /ISICN <br /> I UST 'CR�SHEET FCR SIT_ CL.=RE E'/ALUATtCN OATEI 1 (a/4`� <br /> IuAME IF FACiLIT7 S/1G`� L 1 1 <br /> ScAr'4ICC. J`� 6y� ISL E?S C.�E I 1�jDQ <br /> IACORESS !AHK ID . —~ <br /> 43 5 Wcti-Fcsloc, �Gd �' 13�t=lHao- o1 <br /> t TANK SIZE I '-FUEL TYPE l L„EAp/uNLJEADl <br /> II, iZXERAL IN :ilSTGRT <br /> is permit cirrane?IYes lNoPermitPermit f{ 1-} O (Facility Status Ciel C:)2 IDoc.Soit/cj C ncl'!ez x Nol <br /> Nmoer of Tanks at faeiLiyl Age of ranks(lf avaiLackc)I3O T4riype of rankisteell�( Fbrgl ISngLI Duan <br /> III. TANX ;41STCR7 Illy <br /> (Vas rank :este ?ITeslX INoI (Failed Precision test 1IYes� INoIxIIf yes, give dates) <br /> "ias a -e^.eir made :o the tank sys-e=? Yesl Ac lIf yes, what was repaired7l ��� "`i <br /> 1 0l�. o $44 O IA 1� 3 <br /> Vas repair <br /> done 1.zd r irtspection?Iyes l lMe x (Vere soil samples arsalyzedllTesl No, 3TXEf (TP4-GI ITP4-0+ IPb/Z:78I <br /> �Type of ,'ailuro/disciargel Icacastroo icI ILong-tarn leakage I IaverfiLLI IU*r'c. other- <br /> i'/. AE:!C1AL AISTCRT (ATTACH IASPECTXW Z£PC2T FCR SITE O£TAILS/C)LL_CT OATA FC2 L:AUINIGMTEXTIAL ANALTSIS) <br /> (Sail Samples .iecaivedlyesl INoI IDeptta t0 Grxr,d Vatarl IRef/Y4arl ; (Average Arcual Precipitin onlA-114 I10-?5 <br /> ICn-Site VetL(s) yes{ INaI"x- lNumer L Type) Ilrrl IOeml p'tI <br /> S Scare S Sc--re S Scare <br /> IOistance :0 'JetL(s) from Tank ft; ft; ft C 10 acs C 9 acs C 5 acs <br /> 0 if 0 if 0 if <br /> R condi t i on l Z condi t 1 on R c^..rsdi t i cn <br /> V. Sit_ Festur_ - Leaching Potential Analysis = is net I his nem E is net <br /> (Minimum Jec. ch :a gritzxcwater from the Soil Samote (feet) I I >100 I I51-100 <br /> �Frac::res in sucsurfacs (apoties to focc2tills or notncain areas) I 1 I gorse I ( Ur nown (Present !I <br /> ;Average Arrxtal ?recipitatian (inctes) xzzzxxl ,10 I 9 l 1Q-,5 lxxz==l :5-1. J <br /> I J <br /> Nan-4ade co-4uit3 whims increase vertical aigration <br /> Iof '.eacnate (I.e., sapcie systems, water wetts, ands) ` Nana I Urk.wwn ( (Present <br /> unicve site features: Zec'sarge area, :parse soil, near--y welts. Horse I At le � (More :� <br /> i <br /> =LLM TOTALA»rOTAL ?OMS <br /> S_a=ta .iesutt: (3 r X CR _) ZANGE IF TOTAL POINTS G9 pts nr none l :1 - :3 ,Cts I ,a atm nr l"ems <br /> $ < 2, <br /> T 3: 3� r X ! = 3 T 11 <br /> ti (OcMAXI" ALLCUABL: 3-r-X-_ LE=VELS (PPf1) 1( ;0 ;Q, :Q 3 J..3 1.` 1. ' NA�3 <br /> ISampta zesutt: I GASOLINE 1000 I ,QQ I 1a <br /> lIAXINL71 ALLCYABL: TP4 L_-vELs (M) <br /> TP4 DIESEL 10,000 I 1000 l 100 <br /> r•=T?ICiTE]: f dCCmenced sail ardor 3roUsd water :nntaminaticn is Present, do not coacteta :.>e leae:sinq potenciat <br /> analysis. (I.a., site is alr:-wCLy an UGT Contaminacion List for sail or grand wacer.) <br /> \1 If dear-ft is > S f'. am < 25 scare 0 points. If ceat.'s <sj ft., da nac se taDte. <br /> j \2 If precipitation is > :O inane, scare 0 points. <br /> \3 Levels far 3TXSE are ,-ac acolicaoLe at a TP4 corscencration of 10 a;= (assatine) or 100 .::cm (diesel). <br /> VI. STAFF REO-:*E40ATICU/CXC-'.lSIcX <br /> 1. Are 3TX 3 ar 7P4 Csscatc.-atiorss > ALLoraele Lsvets 'yesl ✓ INoI <br /> ?. ieemzaaerr3 Sits C:asurelTesi Viol ✓rlf res, infer :a Sits Mitigation for :vaLuaticnl V <br /> '/II. 7EVIE11 7/ALUATICX - TO 3E CWl-.-I O 3Y A SL9 YISC2/SEYIC2 <br /> C:4C:2 'JITH STAFF 2`•�41E.lOATICX =SUREITESANOI IZEicRM- TO 317c MITIGATICX FCR /ALUATIGIIT_S; INoI <br /> IOArE .2E=_RRE7, / Z� / IDA12E '_T ZA MAIL:, ! / <br /> !NAME ::F <br /> �=/ALUArC2� <br /> _H 10 —Z7.X5HT)�/90 <br />