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SAN ,lCACUi4�r MPUBLIC HEALTR SERYIC`S/ENVIRONMENTAL Ht DIVISION <br /> LIS UORKSHEET FOR SITE CLO=E EVALUATION "%--( <br /> RTE I�� <br /> Ara OF FACILITY I �REC^.RD ID <br /> pREss -- �, • -i 3 <br /> ANK ID .( IoZ os"o j <br /> ToK Sim U p1JEL TYPE!b <br /> GENERAL SITE HISTORT I- I <br /> 'is oer-niC current? is �lo ty oe.Scil/GU Cont es I p <br /> aciEi Status Code I o <br /> uuroer of Tanks at facitiry' Age of Tank(if available) type of Tank feel IFbrgl �Snsl Ducal <br /> i['I. iANK HISTORY <br /> :as Tank tested? as o I ailed precision test ? fes c I I[f yes, give dare(s) <br /> Was a repair made to the tank system? as Ro f yes, what was recaired7 <br /> was revair done under inspection? �es �lo ere snit samoles analyzed?IYes �- I TXE �PH-G IfPH-4 LblEDB I <br /> Type of failure/discharge rpatastroo is I Itong-term Leakage �verfT E I they: <br /> Iv. R-EMOVAL HISTORY (ATTACH INSPEL'I08 IE40RT FOR SITE DETAILS/COI LCT DATA FOR LEACHING POTENTIAL ANALYSIS) <30-r <br /> Soil Samoles deceived r s I Io I �epth to Ground Vater 0(*f/YearI verage Arcual Precipitation H4 �0-25 -ems <br /> 6•:-Site UeLL(S) IYes I IJo umber $ Type Ilrr I poo I pub <br /> S core S core S core <br /> pisrance to Ve(l(s) from Tank I -ft; ft; ft C 0 pts C pts C pts <br /> 0 0 if 0 f <br /> R audition R onditian R ondition <br /> .L Site Feature - Leaching Potential Analysis - �is met c is met T1s met <br /> :fini=m Depth to grouziduater from Lane Soil Sample Cfe_t) I >i00 �1-10C I 25-50\1 <br /> Fractures in subsur-race (applies to foothills or mountain areas) �.� INone I I Unknown I present <br /> Average Annual Precipitation (incnes) xxxxxxI <10 I 9 110-25 I26-40\2 <br /> Man-Made conduits which increase vertical aigration <br /> bf leachate (i.e_, septic systems, water wells, ponds) Kone Unknown + resent <br /> Unicue site features: Recharge area, coarse sail, or wells. At [east ore than <br /> ChE xwipal=>2000 ft; domestic=>500 ft; irr/agriculturat=presenq I None ! one h one <br /> 'r Ki ISS <br /> COLUMN TOTALS>>TOTAL POINTS <br /> Samwie Result: CB T X OR E) RANGc OF TOTAL POINTS 9 pts or more 41 - 48 pts I 40 pts or less <br /> 13 !'S X- �i j ]n MRXIMUM ALLOWABLE B-r-X-E LEVELS CPPM) 1 ( 50 50 JE <br /> 50 _3 �.3 1. 1. NA <br /> smoke Result: �3 Ll HE 1000 I 100 10 <br /> _ 7 a" r7' IMUH ALLOWABLE TPH LEVELS (PPM) <br /> 'rK VH [E5Ef 10,000 I 1000 100 <br /> FCOTNOT.-ES: .—If dor-menred soil and/or ground water contamination is resent, do not conQLeta the Leaching potential <br /> 7_�"%tS,C��S-z /jJ1WPP4na(ysis. 0.a_ site is currently an Ucr Contamination List for soil or ground water.) <br /> 19 If depth is > 5 ft. and a 25 ft., smre 0 points_ If depth =5 ft., do not use table- <br /> \2 If precipitation is > 40 inches, score 0 points- <br /> i L Levels for BTXbE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (dieset)_ <br /> °fi. STAFF RECOMMEVDATION/CONCLUSTOM FW <br /> LI'`' <br /> / 1 <br /> 1. Are BTX s -9 or TPH Concentrations > Allowable Levels es o ,�[� Ab /. <br /> � 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evatuatian 3- 1 -7` ! -7 4416 <br /> v11. REVIEW EVALUATION - TO BE COMPLETED SY A SUPERVISOR/LEAD SENIOR <br /> :.+CUR WITH STAFF RECOMMENDATION FOR CLOSURE ESI �0 EFERRED TO SITE 141TIGATICt! FOR EVALUATION �ES �O <br /> �AEE REFERRED / / DATE COSURE LEIM MAILS <br /> ?TAME OF <br /> VALUATOR <br /> =H 13 80 (UGTWXSHT)\5/94 <br />