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Crt " 9LIC HEALTH SERVICES/EWRONMENTAL HEAL: "'IVIS <br /> 'IVISI <br /> SAN 1QAQUIN ON <br /> PU <br /> - -'WMSHEET FCR SITE CLOSURE EVALUATION -'- OATS <br /> NAME OF FACILITY SAPS CGDE I <br /> AOOR£SS TANK i0 11 O <br /> TANK SIZE FUEL TYPE , <br /> ti. GE14E�RAL SITE HISTORY <br /> Is paresis current? Yea No Permit #. Facitttj Status Code Doe.Soil/Cv Conc Yes Na <br /> Number of Tania at facilityAge of Tanks(if available) Type of Tank Steel jFbegi Sn391 I Dust <br /> 1 11 <br /> III. TANK H I STORY <br /> Was Tank tested? lea Nal I Failed precision test 7 Yes Na It yes, give dates) <br /> vas a repair made to the tank.systearl Yes Ito If yrs, what was repeired7 <br /> was repair done wader iaspestionT Yrs No vers soil sanples analyzed? Yas No BTXE TAN-G TPN-D _ P4/ED9 <br /> Type of failure/discharge catastrophic Long-term leakage overfill u*nown other: <br /> IV. RECYAL HISTORY (ATTACH INSPECTION REPORT FCR SITE OETAILSMOLLECT DATA FOR LEACIIINS POTENTIAL ANALYSIS) <br /> Soit SaMtes Received Yes lie Cepth to Grosd Water Ref/Year Average Arranl precipitation Ay 14 10-25 <br /> On-Site 'MOMS) Yes No Number i Type .!' ier Dom Pub <br /> S Score S Score S Score <br /> Distance to veLL(s) from Tank i <br /> f0 f f i <br /> 0 f 0 t; eft; ft C pts C pts C i QCs <br /> if <br /> R condition R condition R condition <br /> V. Site Feature - Leaching Potential Analysis E Is aet E is met E is met <br /> �Ninimua oepth to grourduater from the Soft Sample (feet51-100 ZS-"50\1 <br /> Fractures in subsurface (applies ,o foothitts'or aantain areas) Hone Urn Present <br /> i- <br />' Average Arcual Precipitation (taches) xxxxxx <10 9 10-25 xxxxxxx 2:;-40\2 <br /> Man-Made Conduits which increase vertical migration <br /> of leachate (i.e., sopor systema, water wit's, ponds) <br /> None Womorn " ,Present <br /> Unique Site features: itecharge area, coarse sail, nearby wells. At Least Mort than <br /> xxxxxx Nara one ane <br /> =LUNN TOTALS»TOTAL POINT$ • (2 <br /> Sample Result: t8 T X OR "c) MMj:E OF TOTAL POINTS 44 pts or more 41 - 4a Qts 40 pts or less <br /> �I SQ 10 Ob I T X E EI T X g . <br /> MAXIMX ALLUMLB 3-T-X-E L>:VELS (PPI) 11 50 5o 50 .3 .3 1. 1. NA\3 <br /> Saapte Resut• G7LSOLINIE 1000 too 10 <br /> Ai( (U b, 11AXl" At.LOVABu TP11 LEYELS (PPM) <br /> TPR DIESEL 10,000 1000 100 <br /> j FOOTNOTES: "'*If dotzmented soft and/or gronsd wale' contamiaetias is present, do not **opiate the Leaching potandat <br /> analysis. (i.e., site is awrenely on UCT Contamination List for sail or ground water.) <br /> \1 If depth is > 5 ft. and < 25 ft., scars 0 points. If depth 4=5 ft., do not use tabte. <br /> \2 if precipitation is r 40' inches, score D points. <br /> \3 Levets for MU are not epptieabte at a TPN concentration of 10 ppm (4ssolfne) or 100 ppm Cdtesat).. <br /> Vt. STAFF RECCMIWIDATION/C)IICLU3t011 <br /> c�cS n trek-44 <br /> t. are 3TX or TPN CavAntrations > AitoMable Lawls`'Yes No All <br /> 2. Recommend site Closure Yes 1No '� If Yee, Rsftcr to site Mitigation for EraLuatioUNC <br /> n a <br /> VII. MIEW a. "'r - To air CO1 PL F� 3T A 2AMVISORISEXICR ,1�.J�U• <br /> CCMM2 14ITH STAFF RECMMMATION FOR CLOSURE YES .1mo IREFERRED TO SITE MITIGATION rQN EVALUATIONIYES go <br /> CATE ISFERRIM / / DATE CLOSURE LETM MAID / <br /> : NAME :F <br /> EVAL'-IATCR <br /> EH 23 a0 (Ut;T%ACS%T)\5/90 <br /> k� _ <br />