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SAN ,)OAC TY PUBLIC HEALTH SF_RViCS/EMVIRCHMEVTAt - OIVISICH <br /> I ti� �dST VCRKSHE_T FOR SME CLOSURE Es/ALUATIL,. N.,,, OATEI 7 3 �� <br /> (NAME OF FACILITY I Q. /ZL f�� LC!� ISu�S cco-1 _�3 / 161-5 <br /> 1 ADDRESS 15/ D E �/� � i TANK ID dI - J ,�,s► <br /> TANK Sim` IDf � (Full- 4E <br /> II. GENERAL SITE HISTORY <br /> Is Fermit current?IYes INo! Permit �I - iFacility Stats:s Code) IOoe.Soil/G-1 Czntly"I INoI <br /> Vomer of Tanks at ype faciliryl 3 (Age of Tanks(if available)1 ; of Tank Steell IFbrgtl ISngII Ouall <br /> ::I. TANK HISTORY <br /> :as Tank tested?IYes( INoI (Failed precision test ?IYes)X INoI If yes, give date(z)1/0/ <br /> :as a repair mode to the tank system? Yesl Nal 11f yes, what was cepaired?I <br /> :':as repair done under inspee;ion?IYesI INoI Were sail samolrs analyzea?IYes+ INoI STXEI ITPH-GI ITPH-1 IPb/EDBI I <br /> `Type of failure/discsargel Icatastropnicl (long-term leakage) (overfill) (unknown) IaCler: <br /> :V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE OETAILS/COLLECT OATA FOR LaC:m POTcVTTAL ANAL:'SIS) <br /> SoiL Samotes Received Yes INoI (Depth to Ground Vater) (Ref/Year} (Average Annual PreeipitationlA-1116 110-251 <br /> (Cn-Site VetL(s)IYes I INoI INuaner 3 TypeT <br /> l rrl 10cmI IPM ` <br /> S (Scare S Score S Score <br /> �Oistance :o Vell(s) from Tank) ft; `: C it) pts C 9 pts C 5 pts <br /> O if O if 0 if <br /> R cot ftian A condition R condition <br /> V, Site Feature - Leaching Potential Analysis = is net i is most Ic is met <br /> '4inimum Oenth to groundwater from '-*so Sail Samdte (fret) I >100 I 151-1C0 1 I s-50\1 <br /> =^acturrs in subsur=ace (aeplies :a foothills or Tx=tain areas) Hone i I f:rsknawn 1 IPresrnt <br /> I' <br /> [Average Annual Precipitation (inches) IxxxxxX{ <t0 I 9 I t0-S I:ooc:oc:ocl 25-4D\Z <br /> 'Man-Made conduits whir-4 increase remicst migration I <br /> �f leachate (i.e., septic system, water +ells, pants) I None I Unknown (Present <br /> �Unigue site features: ReGsarge area, coarse sail, nearby wells- At <br /> I A leas I I <br /> Mare than <br /> i Nave II I one one <br /> 1 COLUMN TOTALS----TOTAL POINTS <br /> ISamale .Result: (S T X OR ,) RANGE OF `TOTAL POINTS149 pts or more I »1 - 4$ pts 1 40 pts or less <br /> i <br /> MAXIMUM ALLCWABLE 3-T-X-O LEVELS (PPM) 1 501 50' 50 I .3 l a ` t.) t. I NA\3 <br /> sanete ReSult:,__ .1 GffE 1000 1100 t0 <br /> IMM ALLCUMLE TPN LEVELS (PPM) 10,000 1 1000 I 100 <br /> FCflTNOTES: ^ !f documented sail and/or ground water contamination is preserve, do not complete the Leaching potential <br /> analysis_ (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> \1 If death is > 5 ft- and < 25 ft., score 0 points_ If depth s_5 ft-, do not use tabte- <br /> \Z If precipitation is > 40 inches, scare 0 points- <br /> \.3 Levels for 3TX&E are not appticabte at a TPH concentration of 10 ppm (gasoline) or 100 ppm Cdieset). <br /> VI. STAFF RECCMME?1DATICN/CClCL=ICN <br /> 1. Are 3TX b 5 or TPH Concentrations > Allowable Levels I*Yesl INoI <br /> 7 <br /> Recommend Site Closurel7esl 1Ho' ?[f Yes, Beier co Site Mitigation for _valuatfcn <br /> VII. qE,/TEW =VALUATION - TO 3E C=MPLEFTED 31' A SUPa-AVISOR/SSICR <br /> (=NCUR WITH STAFF RECCMMEYOATTCN FOR LOSURElYESI INOi IR£FcZRED TO S;T"c MITIGATION FOR -/ALUATICNIYESI IHOI I <br /> DATE REFERREDI (DATE CLOSURE L_°7TER MAID( i <br /> NAME OF <br /> E`/ALUATCR 1 <br /> °H 3 <br /> 80 (UGTWKSHT)\5/90 <br />