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SAX JOACUtN C{ LIC HEALTH SERVICES/ENVIRCHkEyTAL Hf Ai lSiON ATE 'L( <br /> U' W=SHE. <br /> T FOR SITE CLOSURE EVALIJATICH <br /> !� <br /> A-1 <br /> /� � .�EcPs caoE (6 <br /> AME OF FACILITY i �7af�/ Al" �tANz !D s C76- d <br /> DRESS <br /> rANX SIZE UEL TYPE <br /> Il. GENERAL SITE HISTORY <br /> rs permit current? es , a ermit DO <br /> trot? nudity Status Cade �L� ac.Soil/tu Cant es e <br /> unCer of Tanks at facility <br /> ge of Tanks(if available) ype of Tank Leel brgl ngl Dval <br /> fEi. TANK HI57CRY • <br /> !f. yes, give date(s) <br /> ns Tank tested? es o ailed precision test 7 es <br /> o <br /> Jos a repair made to the tank system? es No f yes, what was rewired? <br /> PH-D <br /> 'is repair done under inspection? Its o ere soil samples analyzed? es o TX£ PH-G b/EDB <br /> ype o[ failure/discharge atastropt+iclong-term Leakage verfill ther: <br /> 1V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> of! Samples Received es o epth to Grocrid Stater a0/ Li/Year <br /> �(Qi ,� verage Annual Precipitation <br /> -Site Wells) es o L umber d Type lrr am <br /> S care S care S core <br /> istance to Wells) from Tank ft; ft; ft C 0 pts . C Pts C pts <br /> O f 0 if 0 f <br /> R otydition R ondition R endition <br /> site Feature - Leaching Potential Analysis E s met. E is met E s met <br /> inimue Depth to groundwater from the Soil Sample tfret) >100 1-100 =725.50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None G Unknownresent <br /> vcrage Annual Precipitation ('inches) XXXXXX 'CIO 9 IO-25 xxxxzx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> f Leachate (i.e., septic systems, water wells; pondx) None Unknown resent <br /> iq,1e site features: Recharge area, coarse sail, nearby wells. At least are than <br /> zxxx None one one LL COLUMN TOTALS--­TOTAL POINTS + - <br /> ample Result: (B 7 X OR E RANGE OF TOTAL POINTS 4 pts or more 41 - 48 pts\ 40 pts or less <br /> T X E <br /> �-.��--- MAXI" ALLWABLE B-T-X-E LEVELS (FPM) I 50 SO 5O NA\3 <br /> ample Result. OLIHE 1000 109 l 10 <br /> IHUM ALLOUABLE TPH LEVELS (PPM) t0O if <br /> +K TPH-6- IESEL 10,000 ' 1000 - si <br /> OOINOTES: ---If documented soil and/or ground water contamination Is present, do not complete the Leaching potential <br /> analysis. (i.e.. site is currently an UGT. Contamination List for soft or ground water.) . <br /> \1 If depth is > 5 ft. and < 25 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 SME are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 Fpm (diesel). <br /> v1. STAFF RECCMENDATION/CONCLUSION <br /> 1. Are 37X &E or TPH Concentrations > AtLowable Levels Yes a <br /> 2. Recommend Site Closure es o If Yes, Refer -to Site Mitigation for Evaluation <br /> •111. REVIEW EVALUATION - To BE COMPLETED BT A SUPERVISOR/SENIOR <br /> ONCJR WITH STAFF RTCCtIMEH0AT10H FOR CLOSURE E5 O EFERREO TO SITE.MITIGATICH FOR EVALUATION ES 0 <br /> i <br /> OTE REFERRED / / ATE CLOSURE LETTER MAILED 7' <br /> IArrE Of <br /> :VALIIAICR <br /> EH 23 80 (VCT6fr<SHT)\5/90 <br />