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SAH JOACUIN ?tSLIC HEALTH SF-gVICES/ENVIRONMENTAL H w JISION <br /> ier <br /> MMHEET FOR SITE CLOSURE EVALUATION ATE Q 6� <br /> AME OF FACILITY pT <br /> _TV ' SuEtPS CCOI: <br /> 4 <br /> LrIt9i <br /> RE55 l C—r 1, - 74 ANl: ID <br /> SIZE ��y $ L TYPE ? J r r/ <br /> s!. GENERAL SITd HISTORY <br /> Is permit current7 es o ermit 9 - aeility Status Code oc.Soil/GLI Conc es e <br /> tanber of Tanks at facility ge of ianks(if available) ype of Tank tcel brgl ngt Dual <br /> III. TANX HISTORY <br /> :tis Tank tested? es o ailed pre,f,;m test 7 es a x if yes, give date(s) <br /> as a repair made to the tank system? es So f yes, what was repaired? <br /> .s repair done under inspection? es oI Mere sail samp[rs analyzed? es a ME PH-G PH-0 /EDS <br /> ype of failure/discharge atastrop4lc1. I[anq-term Leakage erfit[ then: <br /> 'V. REMOVAL HISTORY (AITACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oiL Samples Received i res o epth to Q—jLrd dater of/Year verage Annual Precipitation = 4: 4-25 <br /> -Site Welt(s) bs a umber 3 Type 11 r om b <br /> 5 care S core 5 core <br /> istance to Wells) from Tank ft; _f C; ft C 10 pts C 7 pts C pts` <br /> 0 If 0 if O f <br /> R ondition Rondition tion <br /> Site Feature - Leaching Potential Anatysis E is met E is met s met <br /> inimtam Depth to groundwater from the Soil Same(feet) >100 i-]0 25-50\1 <br /> ractures in subsurface (applies to foothiE[s sr mrntain-areas) Mone yn resent <br /> verage AmuaL Precipitation (inches) xxxxxx <109 0- xxx 25-4012 <br /> an-made conduits which increase vertical migrzzfon <br /> f Leachate (i.e., septic systems, water wells, per,cis) H Un resent <br /> ique site features: Recharge area, coarse =it, nearby weL[s. At Least lore than <br /> xxxx one E one <br /> CCLUMN T0TALS>»T0TAL ?OMS + + f <br /> 3mp[e R//eWit:/](a T dX OR E)� ZANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> r,l? 8 T X E 8 T % E <br /> r <br /> Oaf. ALLO�:A3L:- 3-T-X-c LEVELS (PPM) 1 50 50 50 .3 ..3 1. 1. YA\3 <br /> ample fj CLIME 1000 100 10 <br /> ;Fn <br /> 1Fu1�! ALLOI1A8Ltr I29 LfiVELS (PPM)TPH IESEL 10,000 1000 100 <br /> OOTHOTES: ***If doctmnced soil and/or _q-orid water contamination is present, do not complete the Leaching potentia[ <br /> anotysis. (I.e., site is currently on UGT Contamination List for soil or ground water.) <br /> \1 If depth is > 5 ft. and < 25 ft., scare 0 points. if depth <=5 ft., do noc use table. <br /> \2 If precipitation is > 40 Indies, score 0 points. <br /> 13 Levels for SME are not ax(icabte at a TPH concentration of 10 ppn Cgasol.ine) or 100 ppm (diesel). <br /> I. STAFF RECCIIHENOATIOH/CCNCLUSION <br /> I. Are 8TX E or TPH Concentrations > Attcwable Levets Yes o <br /> 2. Recommend Site Ctosure es a If Yes, Refer to Site Mitigation for Evaluation <br /> •II. REVIEW EVALUATION - TO SE COMPLETED SY A MP---WISCR/S IOR. <br /> CONCUR WITH STAFF RECCHMENDATION FOR CLOSURE fa I 0 EFERREDTO SITE HITIdATICN FOR EVALUATION ES 0 <br /> ATE '�A,c CLOSURE LETTER MAILED f / <br /> JAtlF Of 92 <br /> :VALUATOR <br /> EH 23 80 (ULTUKSHT)%5/90 <br />