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SAH JOACUIR CCUN U)BLiC HEALTH SERVICES/ENVIRONMENTAL HEALTH . 31CH - <br /> I. UGST NCRICSHEET FOR SITE CLOSURE EVALUATICH AiE <br /> nME Of FACILITY F e4 EPS COOE <br /> AHK 10 X <br /> ARK SIZE L TYPE <br /> 11. GENERAL SITE HISTORY <br /> Is per-nit currentT es o ermit 0 lFaciLiry Status Code Sailf Cont 1Yes o <br /> unber of ranks at facility j ge of Tanks(if avaitabte) [Type of Tank teel brgl ngl 0ual <br /> III. TANK HISTCRY <br /> his Tank tested? es a ailed precision test t es o If yes, give date(s) <br /> os a repair made to the tank system? 1,es Na f yes, what was repaired? <br /> as repair done under inspectfon7 es o ere gait saaptes analyzed? es o TXE PH PH-0 b/508; <br /> ype of failure/discharge acastrophic long-term tcakage verfitl Hawn then: <br /> IV. RE14OVAL HISTORY (ATTACA INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samptes Received es o epth to Ground Vater )tet/Year g(p verage Armat Precipitation <br /> -Site uetl(s) es timber L Type Irr an b <br /> S core 5 care S core <br /> istance to Weil($) from Tank ft; ft; � ft C 0 pts C pts C Pts <br /> 0 If O if O it <br /> R ondition R condition R ordicfan <br /> Site Feature . Leaching Potential Analysis E is met E is met E is met <br /> Minimum Depch to groundwater from the Sail SaapEe (feet) 35 t-100 <br /> kr3c:ures in subsurface (applies to foothills or mountain areas) p Vane Unknown resent <br /> avcrage Annual Precipitation (inches) X=X <10 9 10-25 xzzxcz 26-40\2 <br /> an-made conduits uhich increase vertical migration <br /> I leachate (i.e., septic systems, water wells, panus) / D Hone Unknown resent <br /> ique site features: Recharge area, coarse gait, nearby wells. At tease ore than <br /> Kxxxxx None 9 one I one <br /> COLUMN TOTALS>>>TOTAL POI4TS <br /> amplC Result: (B 7 X OR E) ONCE OF TOTAL POINTS 9 pts or more 4] - 48 pts 40 pts or less <br /> X I E B JT X E <br /> MXI" ALLOWABLE B-T-X-E LEVELS (PPM) 1 5D 50 50 .3 .3 1. 1. HA\3 <br /> ample�sue lt: SOLIHE 1000 10 10 <br /> G� I}ItS!{ ALLOWABLE TPR LEVELS (PPH) <br /> r TPH IESEL 10,000 1000 100 <br /> FOOTNOTES: ••'If documented soil and/or ground water contamination is present, do not complete the leachi7(dieseL). <br /> analysis. (i.e., site is currently on UGr Contamination List for soil or grafi wate <br /> \1 If depth is > 5 ft. and -c ZS ft., score 0 points. If depth < 5 It., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or t00 ppm <br /> ;. STAFF RECCI.4IE14OATION/CCNCLUSIO9 <br /> 1. Are 3TX 3 E or TPR ConcentrationsA#t wable Levels yesvvo <br /> 2. Recommend Site Closure es / If Yes, Refe o Site Mitigation for Evaluation <br /> .1. REVIEW EVALUATION - TO SE CCNPLE�EI>8Y A SWEvISCR/SEXIOR <br /> ONCUR WITH STAFF RECCHMENOATION FOR CLOSURE iES 0 EFERRED TO SITE 4ITICATICH FOR EVALUATICH ES 0 <br /> ATE REFERRED / / ATE CLOSURE_LET-TER-MI tED- -� <br /> ♦♦ <br /> IAr.E Of <br /> ;vnLUATOR - 2 <br /> C� <br /> CH 23 aO (UCTWXSHT)\5/90 <br />