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' WBLIC NEAt.TN SERVICES/ENVlR01D�MTAL I�ALTf =tYIS10N DATE <br /> SAN JWMIN COW'` Sair FOR SITE CLOSURE EVALUATION <br /> VORiCEpg CODE1101 <br /> 3 <br /> TAME 7f FACILITY TANK 10 iE 9 -,QeA3 <br /> ADDRESS <br /> TMX SIZE Q FUEL TYPE X� <br /> GENERAL SITE NISTORY <br /> I s perwi t cvrrsnt? Yes No Permit S 3 9' ` <br /> facility Status Coda 6 Da•solt/cw Cot Yes No <br /> Murber of Tanks at facility <br /> Age of Tanks(if svattebteType of Tank Stesl fbrgt Sngt Owl <br /> I. TANK HISTORY <br /> give delete) ��I � /��. <br /> Was Tank testae Yes NO fai tad preclsi test 7 Yes No if yes, <br /> , What was repaired? [.cJ Q,Q <br /> Vas a repair mads to the tank my""? Yes No If yes t <br /> Yes repair done under inspection? Yes Mo dart soil samples anatyzed7 Yes No TXE TPM-G TPN•0 Pb/EDB <br /> Typo of failure/discharge <br /> catastrophic lanp-term teakagt overfill unbonmh other. e <br /> Y. REMOVAL NISTORY CATTACB INSPECTION REPORT FOR $ITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL YS <br /> Soil Samples Reeeivsd YesNo Depth to Ground Yater Rtf/Yesr Avtrsgt Annual Precipitation M114 10-25 <br /> On-Site Vett(s) Yes No Number i Type irr Oar Pub S Score S Score S Score <br /> Distance to Vttt(s) from Tart � t; _f t; ft C 10 pis C 9 pts C 5 pts <br /> O if 0 1f 0 1 <br /> R condition R " condition R condition <br /> V. Site Feature - Leaching Potential Analysis .SO — I Y'3 E is met E is Brat E is mat <br /> minima Depth to groundwater from the Solt Sampte (feet) >700 51-100 23.50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) Q None Unknown Present <br /> Average A mi. Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> Nan-dada conduits which increase vertical migration None Unknown Present <br /> of tesohate (1.e., septic systems, water wells, ponds) <br /> unique site features: Recharge area, coarse soil, nearby watts. At toast More than <br /> hDXU)XD ec None one one <br /> COLL= TOTALS>»TOTAL POINTS I LJ • * . <br /> Sample Result: M T X OR E); RANGE OF TOTAL POINTS 49 pts more 61 - is pts 40 pts or fess <br /> $= + 'x" �r� B T X E Y JT X E <br /> a 1 100 EDOz A60 MAXIMM ALLOaKE B-T-X•E LEVELS (PPM) 1 30 50 50 .3 .3 1. i. NA13 <br /> Sample Result: GASOLINE 1000 100 10 <br /> P ( 3p; j INUi ALLatB►�E TPN LEVELS ( ) DIESEL 10,000 1000 <br /> FOOTNOTES: ***If dochaarted soft and/or ground water contamination is present, do not complete the leaching potential <br /> analysis. (i.e., site is currently an UOT Contamination list for soil or grand water.) <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. if depth s$ ft., do not we table. <br /> \2 If precipitation is > AGO inches, scat 0 points. <br /> \3 Levels for BTME we not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (dfestl). <br /> VI. STAFF RECOIMEND ATION/CONCLUSION <br /> 1. Are BTX i E or TPN Concentrations > Atlowmbtt Levels *Yes No <br /> 2. Reco m wd Site Closure Yes No If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVAWATION • TO K COMPLETED BY A SUPElIY180R/SENtOR <br /> COKLjR VITN STAFF RECOMWVDATION FOR CLOSURE YE5 REFERRED TO SITE MITIGATION FOR EVALUATION TES NO <br /> DATE REFERRED / / DATE CLOWRE LEI n MAILED <br /> NAME OF <br /> EVALUATOR <br /> EN 23 80 (UGTWMT)\5/90 <br />