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SAN ,1aACU11 PUBLIC HEALTH-SERVICES/ENVIRONMENTAL HEA IISION <br /> I 11CRKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> EPS CODE <br /> OF FACILITY <br /> 7_jjA)IK ID : <br /> EF Alp( SIZE "PE W11S1�O <br /> II. GENERAL SIVE HISTMY <br /> .. * permit eurrentT es o eraai t f <br /> ! aeit•ity Staten code oe.Soi /GW. Cont es o „ <br /> r of Tanks at facility �� 9 <br /> elof Tanks(if available) ype of Tank Leel brgt ngl Dual. <br /> GIII- TANK HISTORY 6( '{ <br /> his Tank tested? es o ailed precision test ? es a If yes, give date(s) <br /> as a repair made to the tank system? es No # yes, what was repaired? <br /> as repair done under inspection? es o ere sail samples analyzed? es o T%E PH-G PH-0 b%EDB <br /> ype of failure/discharge atastrophie fang-term leakage verfill known then: <br /> IV. REMOVAL HISTORY (ATTACH INS PE TION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) _ <br /> oil Samples Received es o epth to Ground Water of/Year ���;� verage Annual Precipitation <br /> 1 <br /> -Site Wett(s) es o umber & Type ii. Irr O1P b 5 care S Scare S core <br /> istance to Wett(s) from Tank ft; ft; ft e 0 pts C pts C pts <br /> 0 if O if 0 f <br /> R ondition R ondition R onditian <br /> Site Feature - Leaching Potential Analysis`" E s me[ E lis mer E I s met- <br /> oil Depth to groundwater from the Soil Samale tfeet) l >100 1-10U 25-50\1 <br /> Fractures in subsurface (applies to foothills 'or mountain areas) (] None Unknown Present <br /> t <br /> i <br /> verage Annual Precipitation (inches) zxxx <10 9 10-25 xzxxzx 26-40\2 <br /> 3n-Made conduits which Increase vertical migration Unknown resent <br /> f leachate (i.e., septic systems, water wells, ponds) None <br /> 17 ique site features: Recharge area, coarsejsoit, nearby wells. At least are than <br /> xxx Hone one one <br /> lb :y <br /> COLUMN TOTALS—TOTAL POINTS <br /> Emote Result: (8 T % OR E) RANGE OF TOTAL POINTS 9 pts or more 41 p 0 pts or less <br /> a' <br /> i clzw �t'c.�2l�r<< B T % xMAXIMLH ALLOWABLE B-T-X-E LEVELS (PPM) t 50 50 .3 1.. HA\3 <br /> ample Result: L// OLIHE 10a0: 100 10 <br /> II 1" ALLOWABLE TPH LEVELS (PPM) % 100 <br /> tESEL 10,000 1000 <br /> FOOTNOTES: •*"!f documented soil and/origround water contamination is present, do not campiete the leaching <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground water..) <br /> \1 If depth is > 5 ft. and <-f25 ft., seore.0 points. If depth <=5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for STXBE are not appticabte at a TPH concentration of 10 ppm (gasetine) or 100 ppm. (diesel}. <br /> VI. STAFF RECCWEHDATION/CONCLUSION <br /> 1. Are SIX,&E or TPH Concentrations > Attouable Levels has o W <br /> Z. Retoremend Site Closure es o If Yes, Refer: to Site Mitigation For Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SLOERVISOR/SENIOR <br /> -ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE1 0 EFERRED TO SITE MITIGATICN FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> LAME OF <br /> :VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />