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SAN'lCACUIH `5-pUSLIC HEALTH"SCRVICESISIVIRON?I£NTAL HEAL �VI5ION . <br /> I. tiCRXSHEET FOR SITE CLOSURE EVALUATION DATi: 1 <br /> r NAME OF FACILITYOlt 'ROW <br /> PS CODE r <br /> ADDRESS' ! r7 G!`-� � TANK to 1 D <br /> TANK S I21: FUEL TYPE <br /> It. GENERAL SITE HISTORY u�^-�`'=► <br /> Is permit current? Yes, No Permit 0 Facitity 'Status Code g Dae.Soit/GV Cont Yes No <br /> Number of Tanks at facility Aga of TanksCif avaitable) Type of Tank Stee[ Fbrqt Sngl. Dual <br /> IIt. TANK HISTORY <br /> vas Tank tested? Yes No Fatted precision test 7 Yes No If yes, give dates) <br /> vas a repair made to the tank systw Yes No I4 yes, chat was repaired? <br /> [las repair done under inspection? Yes Na Here soil saaptes amtyzeM Yes Na BTXE TP1l-G TPN-D ; MIMS <br /> Type of failure/discharge catastrophic long-tens leakage overfill ustikrmn other: <br /> IV. RE){OVAL HISTORY (ATTACH I cTIOM V.PMT "FOR SITE DETAILS/COLLECT 'DATA FOR LEACHINI; POTENTIAL ANALYSIS) <br /> Soit Samples Received Yes Na Depth to Ground Water Ref/Year ; Average AmAt PricipitattonjAs 14 10-25 <br /> On-Sits vetl(s) Tes No wj*wr L Type Irr Oas P� <br /> S Store $ Store S Score <br /> Distance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0. if <br /> R condition R condition R eoedItIown <br /> V.. Site Feature - Leaching Potential Analysis E Is met E is mat E is mat <br /> Mini" Depth to groundwater from the Soil Sample (feet) I X100 51-100 2550\1 <br /> Fractures in susbsu fees (applies to foothil-ts;or mountain areas) Hone l]nknown Present <br /> Average Anew Precipitation (inches) xx xxx <10 9 10.25 X==[ 26-4042 <br /> Man-Made conduits which Increase vertical aigratian <br /> of Leachate (i.e., septic systems, water wells, ponds) None Ijnbxan Present <br /> Unique site features: Recharge arra, coarse sail, nearby wells. At least More than <br /> xx)o= Raw ane one <br /> COLUW iOTALP"TOTAL POURS • • <br /> Sasote Result- (B T X OR E} RANGE of TOTAL POINTS 49 pts all or <br /> me 41 - 48 pts pea or Less <br /> MAXIMLII ALLOHABLE 3-T-X-E LEVELS (PPtq t 50 50I 50 .3 J.T3 1.1 I l 111A\3 <br /> Sample Rasa t GASOLINE loco 100 I0 <br /> 41 <br /> / uxim I ALLONABLE TPN LEVELS"{PPM} <br /> TPN OIESEL IO,00O lobo 100 <br /> FOOTNOTES: —tf do�aented soil mWor gromcl water noataSinstion is present, do not complete t,�e t <br /> aneiysis. (i.e.. site is currently an UCT Contamination List for soil or g water.) <br /> \I .If depth is �, S ft. and < 2j ft., wort 0 points. if"dnp"ch �=5 ft., do not use table. <br /> \211 precipitation is s 40 inches, :core 0 points. <br /> 13 teals for,3TXU are rat'applieabte at a TP1E corosatratian of 10 ppm (.9nolina) or 100 X0 W10260- <br /> 'it. STAFF RECCKtWAT1OK/C=C=IOK S Ti4A) <br /> I. are 3TX & S or, TP4 Caneentriclans > Attarable Laws *Yes Na. PP <br /> 2. .Recommend site CtasuueelTq Na tf Ya, Refer to site Mitigation for rvatuaeian <br /> . , �.Z <br /> VII. -MIEII EVALIIATIOII - TO 3E CQW%ETEA 3Y A SIX4=SOR/SENICR <br /> =NC71 JITH STAFF RECCHOCENDATICH FCIt CLommalES <br /> lTI NO1 REFERRED TO SITE MITIGATION FCR EVALUATION1YES# 1XOIL <br /> 1 <br /> DATE REFERRED] ! ! DATE CLOS>U LETTER NAILED <br /> HAKE :F <br /> t EVALUATCR <br /> SH Z3 as (UGn,=HT}\5/90 <br />