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SERV HEAL'VISION <br /> SAN SOACUTN C PUBLIC HEALTH ScR ATE I( <br /> € U ST WRXSHEET FOR SITE CLOSURE EVALUATION <br /> AME OF FACiL1T7 <br /> �7y'/ E_ �� .tEEPS CooE 1b t k <br /> ANK IB 9 tljffj' a <br /> r3DRf�1�5 IF <br /> LAN% D UEL TYPE <br /> [I. GENERAL SITE HISTORY <br /> €s permit current? es o <br /> ermit 9 QD ����� aeility Status Code !� oe.Soil/GW Cant es a <br /> Ij <br /> under of Tanks at facility g <br /> e of TW*S(if available) ype of Tank tee[ brgl ngl Dual <br /> III. TANY HISTORY <br /> ns Tank tested? es o ailed precision test 7 es a If yes, give dates) J I <br /> as a repair wade to the tank system? Ives No f yes, what was repaired? <br /> as repair done under inspection? es a ere soil samples analyzed? es o• TXE PH-G PH-D bIEOB <br /> ype of failure/discharge atastrophic long-term Leakage erfi[E' own Lhcr: <br /> IV. REMOVAL HISTORY tATIACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oD% verage Annual Precipitation = 4 0-25 <br /> oil Samples Received es o epth to Ground Vater /6(p efJYearf�y <br /> -Site Weil(s) IYes o umber b Type rrS 3core 5 Score S. core <br /> istance to Wells) from Tank ft; ft; ft C 0 pts C pts C Pts <br /> 0 if 0 if 0 f <br /> R vnditian R condition R ondition <br /> Site Feature - Leaching Potential Analysis E s met, E is met E s met <br /> inimum Depth to groundwater from the SOI[ Sample (feet) >100 � 1-100 { 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) Wax:. C11Unknown resent <br /> %vcrage Annual Precipitation (inches) c10 9 10-25 xxxxxx 26-4012 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) one <br /> Unknown resent <br /> leve site features: Recharge area, coarse sail, nearby weds. At least ore than <br /> xxxx None one one <br /> COLUMN TOTALS—TOTAL POINTS +: + qorlel <br /> ampte Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more40 p <br /> 17' od .o2p�►*t B T X E B T X E <br /> . <br /> Z-0 bo"1 NAXIMLH ALLOWABLE B-T•X-E LEVELS (PPH) 7 'S0 50 50 .3 3 1. i. NA\3 <br /> ample Result: OLiNE i000 10 <br /> 100 <br /> IMUH ALLOWABLE TPN LEVELS LPPM) 100 <br /> TPH-G I ESEL ;10,D00 1 DOO <br /> OOTNOTES: *"If documented soil and/or grand water contamination is present, do not complete the leaching potential <br /> analysis. (i.e.. site is currently on UCT Conta<aination List for soil or ground water.) <br /> \1 if depth is j, 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. ; <br /> \3 Levels for STXSE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> '11. STAFF RECCMENDATION/CONCLUSION <br /> 1. Are BTX E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure zs v if Yes, Refer to Site Mitigation for Evaluation <br /> ,ill. REVIEW EVALUATION - TO BE COMPLETED By A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECCkOiENDATTON FOR CLOSURE ES 0 ]REFERRED TO SET£ MITICATICN FOR EVALUATION ES 0 f <br /> ATE REFERRED / / ATE CLOSURE LETTER HAILED f / <br /> AAME OF <br /> :VALUATOR <br /> EH 23 50 (VGTwXSNT)\5/90 F'T <br />