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SAN JCACUIH ` PUBLIC HEALTH SERVICES/EHVIROMMEXTAL HEAL'-"'`*�YISIa <br /> i �I LC:R7CSilEET FOR SITE CLOSUREYALUATiOlI [ DATE C <br /> �. ��. <br /> NAME OF FACILITY s.rcPS CODE / r./�j/� <br /> ADDRESSr� _]TANK ID S I i0.Q Q / <br /> TANK SIZE Ili FUEL TYPE (L re yy� Q Ve CL "7/ "/ 50 .� <br /> B. GENERAL SITE HISTO I <br /> ♦7i <br /> Is permit current? Yes No Permit S - Facility Status Code Doc.Soit/W Cont Yes N <br /> Murnber of Tanks at facitity Age of Tanks(if avaitabta} , Type of. Tank Stett Fbrgt Sngl Owl <br /> sit. TAH% HISTORY <br /> 4as Tank tested? Yes No Failed precision test 7 Yes Na if yes, give dates} <br /> L: <br /> Was a ---pair made to the tank system? Yes 110 If yes; what was repaired? <br /> Yes ,-epos- done under inspection? Yes No bare soil samples analyzed? Yes No' BTXE TPR-GL TPW-0 Pb/1 <br /> Type of failure/discharge catastrophic torp-tars teokage overfII cs ,t ocher: <br /> IV. ZEMOYAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING :POTEATIAL ANALYSIS) <br /> Sait Samptes Received Yes No Depth to G ,ra" Yater Atf/'fear 80 Average Amin Prteipitatfon A-114 10-25 <br /> On-Sirs Yelt(s) les No 'Nusber i Type irr Oaa Pub <br /> S Scare S Scare S Score <br /> Distance to Welt(s) from Tank ft; ft; ft C 10 Pts C 9 pts C 5 pts <br /> O i:f 0 if 0 if <br /> R condition R condition R Condition <br /> V. Site Feature - Leaching Patenciat Analysis E. is -met E is met E is met <br /> Minimum Oepth to groundwater from the Sait Sample (fan D j,% >1d0 �51-10(i Z5=5d\1 <br /> Fractures in subsurface Cappties to foothitts:or mo retain are ) hone Unknown Prt�enc <br /> Average An ust Precipitation (inches) xl0000t <70 9 10-ZS �oaotxxx Z6=4d\2 <br /> f <br /> Man-Made canduits which Increase vertical siyretion <br /> of Leachate (i.e., septic systema, water wafts, ponds) None Unkrwrins Present <br /> Unique site featuresi Recharge area, comma soil, nearW-woUs. Q At Least Mari then <br /> xxxxxoc Wont i ane one <br /> =LMTOTALVi-TOTAL POINTS <br /> Sar t� X"utpt: (3 T E}� f� S"GR OF'TQTAL DOtNT4 49 pts or <br /> or se 41 - 43 pt 0 pts or Less <br /> a T X E E T X E <br /> 1 Mr XIM M ALLt7AMU 3-T-X-E LEVELS (PPM) i 50 50 50 .33 1 i MUt\3 <br /> La o III_ 1VucIMUM ALLMUU TP1i LEVELS (PPN) r.ASotINE 1040 100 10 <br /> TPI DIESq. to,= 1040 140 <br /> OOTWOTES: —If doe�nleneed soil and/ar grand water eoncaainattan is present, do not comptato tMil earbing`Patma L_ . <br /> anstysis. (i.e., site is aarentty an UGT Contamination List .for sait or graxsd slater.) <br /> \1 if depth is � 5 ft. and c ZS ft., score 0 points. If depth cw9 ft., do not use tsbtt. <br /> \2 If precipitation is > 40 rw:hos, score 0 points. . <br /> \3 Ltvats for 3TXEE are not'appticabLe at a TP1 concentration of to PM (gasotina) or 100 ppm (dieset) <br /> VT. STAFF RECO MVMATION/C=CLUSIOM Ir`ti�� Q Oeje—.0a1,t4 <br /> t. Are SIX b : or TPk Coneentrstiona > AllarabN Lerelsn�rJ <br /> Z. Raeammend Sita Ctosure Yesj na tf Yes, Rift' to Site Mitigation for Evaluation IVO Stec-P,P i ,dpfCS <br /> V11. MIEY EVALUATION - TO 3E C011P1.EM 3T A 'SL1PCMSMU11IOR �'r <br /> CCRCA 14ITH STAFF XECMMMATI= FCR CLOSYIR$ YES H01 26FOSM To SITE MITIGATION FOR -EVALUATION�TE5� I� <br /> DATE IEFERRED / ! DATE CLOSUIIE L$TTER MAILS <br /> E`lALUATAT CR <br /> EH 23 30 (UG'T'MSHT)\5/9G 1 v <br /> _......._:........._..,......_. <br />