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SAN BOAC -Y PUBLIC :1EALrH ScRViCrS/E4VIRCNMEHTAL OIVISICH <br /> 1. %%,W 14R5T 'JCRKSHE]E FOR SITE C:.OSURE EVALUATIC+� OATE I ' J 3 <br /> INAME OF FACILITY C, lsuEz a,3 l 5 1 <br /> iADORESSI IT�jiHK lD :'3 • J / ,� <br /> TANK S I ZE l y f}d I FUEL TYPE C49 <br /> (I. GENERAL SITE HISTORY <br /> ;(s permit current?(Yes Hol (Permit XI (Facility Status Cade a;�- lOec.Sail/G'.J C:ntlYesi (HCI <br /> NL=er of Tanks at facil(tyI IAge of Tanks((f availaole)I � Type of TanklSteell IFbrgll ISngtl Ouall 1 <br /> ::I. TANK HISTORY <br /> Was Tank cested7IYes l INaI (Failed precision test ?iYes l x IHeI IIf yes, give dace(s)IR61 <br /> ':as a repair rade :o :he tank systenrllYesl No 1i yes, what was repaired?) <br /> :':as repair done under inspection?iYes l (MCI Were sail samples analyzed?IYes l INCA IBTXEI ITPH-Gi ITPH-71 IPb/081 I <br /> 7yce of failure/discharge) (catastrophic) (tong-term Leakage) (overfill) -,i--I Iot.Zer: <br /> (V. IEMOVAL ;HISTORY (ATTACH IHSPECTICN REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POT-c.4TiAL ANALYSIS) <br /> Sail Samples Received Yes INoI (Depth ;a Ground Vater) (Ref/Year) (Average Annual PrecipitationlA=114 110-251 <br /> Cn-Site Well(s) Yesl INai INumoer & Typel trrl 10.1 Iftmi S (Scare S Scare S Score <br /> !Oistance :o 'Jell(s) from Tankl ft; t C �i0 pts C 9 pts C 5 pts <br /> O if C (f 0 if <br /> 2 condition R condition R condition <br /> IV. Site Feature - Leaching Potential Analysis _ is set is met is set <br /> Minimun Oeoth :a groundwater `ram rte Soil Samote (feet) I ( >TOO I 151-100 I i zs-s0\1 <br /> IF^ac:ures in subsur=aee (aepties :o foothills or mountain areas) ' Nene 1 I Unknown I Present <br /> (average Annual Precipitation (inches) Ixxxxxxl 10 i 9 I 10-:5 j=x=ctl Z5-40\2 I <br /> 'Man-Made ccnduits which increase vertical migration <br /> ( <br /> of leachate (i.e., septic systm 1, water '+ells, ponds) I I None Unkrsawn I Present <br /> :unique site features: Recharge area, coarse sail, nearby wells. 1=,= I At leas More than <br /> Norte one one <br /> I <br /> iCOLUMN TOTALS»>TOTAL POINTS I <br /> ISampLe Resut:: <B t X OR _) RANGE OF TOTAL POIHT+9 pts or more I 41 - 4a pts i 40 pts or less 1 <br /> MAXIMUM ALL.^YABC£ 3--t-X-=- LEVELS (PPM) 1 50f 50� 50 3 f 1.i 1, NA43 i <br /> i <br /> Samole Result: GASOLINE 1000 I 100 I 10 <br /> MAXIMUM ALLOYABL_ TPH LEVELS (PPM) <br /> TPH OIES-r— I 10,000 I 1000 l 100 <br /> FCCTNOTES: `„if doc merited sail and/or ground water contamination is present, do riot cahotete the learning potential <br /> analysis. (i.e., site is asrrently on UGT Cmtamination List for sail or ground water.) <br /> \1 If death is > 5 ft_ and < 25 ft., scare 0 points_ If dents —5 ft-, do not use table- <br /> \2 If precipitation is > Q Inches, scare 0 ,points_ <br /> \.3 Levels for 3TX&E are not applicable at a TPH concentration of 10 ppm (gasatine) or 100 ppm (diesel). <br /> VT. STAFF RECCMMENDATION/C NCLUSICU <br /> 1. Are 3TX 3 E or TPH Concentrations > Allowadte Levels I'Yesl INo <br /> 2. Recoam u Site Closure Yes INoI rtf Yes, .Refer to Site Mitigation for =vatuatian <br /> VII. REVIEW FVALUATICH - TO 3E C=MPL_°TED 3Y A SUPERVISOR/SE)IICR <br /> iC=NCJR WITH STAFF RECCMME40ATICM FOR =.OSUREjYESI INOi IRF-r----MED TC SI—,E. .4ITtGATTrx FCR E</ALUATIONiYES' INC! I i <br /> DATE REFERRED( / / (DATE CLOSURE LcTE.Z MAILS-3 <br /> NAME OF <br /> EVALUATORI <br /> EN 3 80 (UGTWKSHT)\5/90 <br />