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SAN ICAGUTA =,­' Pt1BLCC HEALTH SERVICES/ENVIRONMENTAL HEAL tVISIOR <br /> I VCA!(SNEET FOR SITE CLCSUR$ EVALUATION OA7"e <br /> re ^^ J / <br /> NAME OF FACILITY CODE r I <br /> TANK SIZE OaO FUEL TYP: A U G..-H <br /> 1I. GENERAL SITE HISTORY Q ... <br /> Is permit current? Yes No Permit t - Facility Staten Code Ooe.Soil/CW Cont Yea No 1 <br /> Hunber of Tanks at ficitity Ag* of Tanks(if available) '- Type of TaNc Sleet F6rsl Sngl Duet <br /> III. TANX HISTORY <br /> Was Tank tested? Yes No failed precisiail test 7 yes Ito If yes, giv* dates)) <br /> zil <br /> Was a repair mode t Lige tank system? Yes No If y*!, what was repeired?l <br /> Was repair done under inspection? yes No Wer• gait samples analyzed? Yes8TX8 TPH-G TPII-D ° .PblEDS <br /> No <br /> Type of failure/discharge catastrophic tong-feral traka9e wmrflii a �knarau ; other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTIOU REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACRING POTENTIAL AMALYSIS)• <br /> Soil Samples Received Yes Ito Depth to Gratsd Water Ref/Year ; Arsrnge Anneial Precipitation As I4° 10-25 <br /> On-site VeIL(s) Yes MC Nuober i Type I1rr Dam Pub <br /> S Scars S Scars S Scars <br /> Distance to Welts) from Tank ft; ft; ft C 10 pts C 9 pts C 5'pts <br /> 0 if 0 if 0 if <br /> R corditidn R condition R condition <br /> IV. Site Feature - Leaching Potentia[ Analysis 2 is met E is net E is met <br /> Minimua Depth zo groundwater frac the Soil Sample. Cfeet)36— 11, <br /> "r )100 k5t-iO0 -z5-5o\1 <br /> Fractures in stAmrfaee (app0es to foothills or nomcain areas) Mane Unkr+own Present <br /> Averige AnrxjaL Precipitation (inches) 9 10-Z5 )ooc7aaoc Z6-40\2 <br /> lean-Made conduits which increase vertical aigrstion <br /> of teschate (I.a., septic systems, water watts, pards) MGM Unknown Present <br /> Unique site features: Recharge area, coarse soft, rwarby welts. At Least Mar* than <br /> r00000t Mone � one ane <br /> GCLUNK TOTALPi TOTAI. POINTS • [Q • <br /> sample Resutt: (3 T X OR S) ..RANGE Of TOTAL POINTS 49 pis ar nore 41 - 4$ pts Opts or Less <br /> ore, MAXIJlL71 Ai.1.CiAN1 E 3-T-X-ii LEVELS (PPM) B 50 50 50 .3 .3 1.1 I NA\3 <br /> Tl X I <br /> , <br /> Sample Result: GASOLINE low 100 10 <br /> k `' )(IMUM AUMULE TP11 LEVELS (PPM) <br /> /r !IA <br /> Tp, DIESEL IO,DDD Iona .loo <br /> FOOTNOTES: *"If documented soil aMlorL grand water contamination is presant,'da not complate th caching'pot <br /> analysis. (i.*., site is aurrentty an UGT Contamination List for Boit or ? <br /> \1 I#.depth is 2. 5 ft. Ord < 8 ft., sears O points. If depth a5 ft., do not orae tadts. <br /> \2 If precipitation is 2, 40 inches, scare 0 points. <br /> \3 Levels for 3rALE ars cot applicable at a TPH con:encrettan of 10 :ppm (42sotins) or lea pM Cdies4L). <br /> Vt. STAFF RECOMMATICK/CGI01 IOM t <br /> t, are 9TX i S or TP11 Concentrations > ALLawbls Levels 'Yes No ` <br /> 2. aeca®err3 Site Clostars Yes Na If Yam, Refer to Site Mitigation for "cvaLuacian Ot-Jfi~ <br /> i <br /> NII. :2EVIEW EVAMTICY - TO 8E C01PL TED RT A Sl)PERYISMSEVIOR <br /> i CtOIC:R VITH STAFF RN:COqILMDATIOM FCR CLOSURE TES NO JIMFERRED TO SITE MITICATICU FOR EVALUATIOMIYES, INO 1 <br /> s DATE 2EFERRED ! ! DATE CLOSURE LET= HAILED ! ! <br /> NAME :F <br /> EVALt:ATCR - <br /> -H 73 30 (UGTWXZHT)\5/9O <br /> sl <br />