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SAN .:CAWIN CCX.'HTY' )(C HEALTH SERVICcSlENVIRCNt1ENTAL HEALTH 0% CN <br /> UGVT�L4EET FCR SITE CLOS(RE EVALUATICN `.� ATE ` 1 <br /> n'E <br /> OF FACILITY , 1 EEPS COOE <br /> r <br /> AOCIRESS �D ` 4ANx 10 x 3 <br /> r <br /> ;TANY SIZE 115 ,gOD UEL TYPE` <br /> ,a GENERAL SITE HISTC _ <br /> {s permit current7 des o ermit a - 00130"n- <br /> acuity Status Code oe.Sail/G;J Conc es o <br /> '+v^eer of Tanks at facility ge of Tanks(if available) ype of Tank Ceel �rbrgt ngl Oual <br /> E'I. TANK HISTCRY <br /> 'r-rank tested? es I VIIO ailed precision test 7es o If yes, give date s) <br /> 'dos a repair made to the tank system? es No f yes, chat was repaired? <br /> :as repair done under inspection? ,fes 40 ere soil samples analyzed? lies o TXE PH-G� PH-0 WEDS <br /> type of failure/discharge atastrophic (long-term leakage pverfill known cher: r' &411 <br /> RE40VAL HISTORY CATTACH INSPECTION 2EPCRT FOR SITE OETAILS/COLLECT DATA FOR LEACHING POTEYTIAL NALYSIS) -4;-6 -%�Pa-ZI-V 7/a <br /> Soil Samoles Received 4es o epth to Ground 'later of/Year g'� ; verage Annual Precipitation = 4 0-25 <br /> ,bri-Site Uetl(s) es o umber b Type Irr cm ub <br /> S core S core S care <br /> );stance to Vett(s) from Tank ft; ft; ft C 0 pts C 9 pts C pts <br /> 0 if 0 if 0 f <br /> R onditicn R condition R :Ord!ticn <br /> I " <br /> Site Feature - Leaching Potential Analysis E is met E is met E s met <br /> inimun Oepth to groundwater from the Soil Sample <feet)j0-1-1 a3 >100 1-100 i 25-50\t <br /> Fractures in subsurface (applies to foothills or moLntain areas) lime I Unknown resent <br /> verage Annual Precipitation (inches) x I <10 .9 10-Z5 zzzzxx I26-40\2 <br /> an-Made conduits cnich increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) J D None ( Unknown DIresent <br /> Jnique site features: Recharge area, coarse sail, nearby wells. ( At Least ore than <br /> xxxx None one one <br /> i <br /> CCLUFN TOTALS—TOTAL POINTS + -ILL .7 L <br /> Samole Result: (B T OR E RANGE OF TOTAL POINTS 9 pts or more. 41 - 48 pts 1 40 pts or less <br /> 6 $ X s r x E a r x E <br /> 11 (Q b 4AXIMLN ALLCWAKE a-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. 4A\3 <br />�ampte Res It: ASOLINE 1000 100 10 <br /> AP J 1 DOO�J AXIMUM ALLOWABLE TPH LEVELS (PPM) <br />!Y D. PH fESEEL 10,000 1000 <br /> _ rY�. <br /> 't0IN0TES: •"If documented soil and/or ground water contamination is present, do not complete the teaching potential <br /> analysis. (i.e., site is currently an UGT Contamination List for soil or grocnd water.) <br /> \1 If depth is > 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 3TX&S are not applicable at a TPH concentration of 10 ppu (gasoline) or 100 ppm (diesel). <br /> STAFF RECC14IEN0ATICN/CONCLUSIO9 4 ay��� <br /> 1. Are 3TX 4. E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br />(. REW EV EVALUATICN - TO 3E CCHPLETED aY A SUPERVISCR/SENICR <br /> CCNCC'R VITH STAFF RECCt?NENOATICH tR CLOSURE �lES 0 I EFE2REO TO SITE MITICATICN FOR EVALUATICN YESI 0 <br /> ATE REFERRED / 1 ATE CLOSURE LETTER YAILEO <br /> an YE --F <br /> :vnLUATCR G' <br /> CN 23 N (UGT4YSHT)\ 0 <br />