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'� /�+,� 3 C usT <br /> SAN J1oAGUII.` }NTT PUBLIC HEALTH SERVICfis/ WIRONMENTAL !' 17 DCVCSION <br /> !. ` Si WORK5HEET FOR SITE CL RE EVALlL1TIoN°_ OATE� Z3/Q:4 <br /> NAME OF FACILITY P� n^g-�-4,� kTIIftQVYrr1++CS �LC iSWi ?S CODE <br /> ADDRESS 1 JG.-5 N Car raw 6-a f(0l v I TANK ID ;*139 '! 3 ZS—O <br /> TANK SIZE 30(o (FUEL TYPE <br /> b <br /> I[. GENERAL SITE HISTORY <br /> Is permit currant? Yes No Permit - Facility Status Code)S Doc.Soil/Gu Conti <br /> Yesi No <br /> l I <br /> Number of Tanks at facility( Age of ranks(if available) uhk (Type of rank ISleet x Fbrgtf Snglf Dual) <br /> 111. TANK HISTORY <br /> Was Tank rested? YesHa X Failed precision test ?{Yes( Naf If yes, give dare(s)� <br /> Was a repair made cc the rank system? Yesf NoI �If yes, what was ired? <br /> Was repair done under inspectian?IYes No t�fWere suit samples ane yzed?IYes NCf BTXFI/TPN-GI TPH-of Pb/EDB <br /> Type of failure/discharge( (catastrophic Long-cerin leakage lave ill Iunicnow IX other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/CIIUXaTA FOR Ismzi XG POTEsfTIAL <br /> 4iellc.. 4 A e� <br /> Soit Samples Received Yesfx,I He Depth to Ground Waterl <� IRef/Yea j "(5 Average Annual Precipitation A-111. 10-25 <br /> on-Site We M s)I Yes f-X Ne lumber & rype f I rr X I Dom f l Pt,6I <br /> S Score S Score 5 Score <br /> oistance to Ne(L(s) fram rank 20 ,ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> fl if o if O if <br /> R cardition R condition R condition <br /> V. Site Feature - Laac.'finq Potential Anatysis a is met _ is met E is met <br /> (Minimum Depth ca groundwater from :he SoiE Samote (feet) f f >i00 I f51-100 ( 5 I. s-SO\I I <br /> Fractures in subsurface <acpties to foothills or mountain areas) I Hone f f Unknown I IPresent <br /> Average AnnuaE Precipitation (inches) f 00 I 9 f 10-25 Ixxxxxxxf 25-40\2 <br /> Man-+fade conduits which increase verticat migration <br /> of leachate (i.e., septic systems, water wetis, ponds) None Unknown jPresenic <br /> (Unique site features: Recharge area, coarse sail, nearby wetls. I f At Lest( More Chan <br /> II Kone it 11 one( one <br /> I COlJ.P1N T OTAL53»TOTAL POINTS I t U � - I L� I LO I, <br /> 6� <br /> Samote Result: (3 T X OR E) RANGE OF rOTAL POINTS 9 pts or more f 41 - 48 f 40 pts or fess f <br /> E X - <br /> j`O w3G aL 1"r�,h MAXIMUM AI.LCWABtz 3-r-X-i L-MLS (PAR} 11 Sa 50I 5fl f 1. E. <br /> NA\ <br /> �5amhpte Result- GASOLINE 1000 f looI 10 <br /> M <br /> MAXIM ALLONABLE TPff LvELS (PPM} <br /> TPH DIESEL i0 ac f loco r I 100 <br /> FOOTNOTES: 'If documented soil and/or ground water comaminacion is PresefM, do not complete the Leaching potential <br /> anaLysis. (i.e., site is currentty on UG-4 Contamination List for snit or g.ouz d water_) <br /> \1 if dePO is > 5 ft. and < 25 ft., score 0 points. if depth <=5 ft., do nos: use table. <br /> \Z if precipitation is > 40 inches, score 0 pairrs- <br /> \3 Levels for aTX&E are not applicable at a rPH psi tion of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> f. Are STX & E or TPH Cancrostraclans > Attowable Lavets 'Yes(x fNC <br /> Z. Recommend Site CtasurefYes f INC �If Yes, Refer cc Site Miti tion far =vatuation <br /> VII. REVIEW EVALUATION - rO 3E COMPLETED 3Y A SLIPE_RVISOR/5c�fIOR <br /> CONCUR SMITH STAFF ..-RECCMMEFDATiON FM CLOSIJREfYEsf INOf IREFEER90 To SITE MITIGATION FOR EVALUATIONjYESj fNOl <br /> DATE REFERRED / / DATE CLOSURE L Zr a 'UIILM I <br /> NAME OF <br /> EVALLIATCR <br /> EH Z3 30 (LJGTWKSHT)\5/90 <br />