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SAN xActlry =R)TY PUBLIC :HEALTH SUVICSS/ENVIRONMENTAL HFALiH OIVISiCN <br /> I. UGST 'uORKSHE:r .-0R SITE CLOSURE _)ALUATICI DATE! <br /> NAME OF FACILITY �/���- (� �/ =F 3 1 �5 I� <br /> AOORESSI 2131 /•/7iC�� ��L�C , ] 1� � TANK ID <br /> TANK SIZE( ` /1�riD (FUEL TYPE( D/le� <br /> (I. aERE.RAL SITE HISTORY <br /> (s zermir current?lyes! 1Mal (Permit dl 1Facility Sans Coder`} Oac.SoiL/CJ Cons Yesl INa <br /> �Nu er of Tanks at facilityl (Age of Tanks(if available)! Type of ranklSreell JFbrgl Nn <br /> Ll 0uall <br /> iANK HIST0R7 <br /> was Tank tested?IYes 1Nal !Failed precision test ?lYesl lgol IIf yes, give dace(s)l <br /> ':as a repair .made to the tads system?!Yes Mol 1I yes, her was repaired?! <br /> 4as repair done under inspection?IYesl INoI Were soil samles arolyzea?lYesl !Nal 3TXEI ITPN-gl (TPN-0l 1Pb/ED13I <br /> Type of failure/discharge! catastraonicl I(cng-term Leakage) laverfiLLI 1,1amoynl lather. l <br /> IV, tEMCVAL HISTORY (.ATTACH INSPECTION RE?ORT FOR SITE DETAILS/LOLL:CT OATA FOR LEACHING POTENTIAL ANALYSIS) <br /> !Sail Saumles ReceivetllYesl INoI l0epth to Grourci Vater! iRef/Year1 !Average Annual PrecipiacianlA= 14 110-251 <br /> Ion-ii ce 'Jell(s) YesI INa( Number i typal [rrl Oaml 1Pval <br /> S (Score S Score S Score <br /> Distance to tel L(s) from Tank) ft; C 10 pts C9 pts C 5 pa <br /> O t a if 0 if <br /> .R coni cion A conai ti an R condition <br /> IV. Site Feature - Leaching Potential Analysis _ is Mt = is aeC l a 13 Set <br /> Miniaam Depth to groumftater from the Sail Saaele (feet) l l >1a0 1 lit-100 l_ 25-i0\l <br /> �:-oc:ures in sucsur.'aee (acpliea to foothills or .n ain areas) j None j .Inkrw n j !Present <br /> ',Average Annual Precipirscian (inches) lxzunej 10 l 9 1 10-3 J=Po LLS( 25-40\2 l <br /> '.Nan-Made :onduits which increase vertical migration <br /> ,of leachate (i.a-, septic system, water •+ells, pone:) I l Mane I 'Unknown I Present <br /> Unique site Features: Recharge ares, coarse sail, nearby weLLs. I At Least! More then <br /> :a:ocar .Vane I onel we <br /> i <br /> ICOLUMN TOTALA»TOTAL POINTS <br /> isaaele Result: (9 i X OR :) .RANGE OF TOTAL POINTS 49 pts or mr_ I 4.1 - :d Pts 40 pts or less l <br /> MAXI" ALLONAMLE 3-T-X L:'VELS Cpcm) t iOi i0 50 .S 1- f• MA\3 <br /> Sample Result: GASOLtNE 1000 1 100 1 10 l <br /> MAXI" au h OIAULE TPN LNES (PPM) <br /> TPN DIESEL 10,000 l 1000 1 100 l <br /> F•bTNOTES: r 'f doamcrcd soil and/or ?round water ==amination is present, do rat co®lete the Leading potential <br /> analysis. (i.e., site is =rrltly on UGT Cahamination List for soil or 3raad water.) <br /> \1 If death is > 5 ft. and v 25 ft-, score a pairs- If depth �5 h do not use able- <br /> \2 If precipitation is > Q inches, Sore 0 paincs- <br /> U Levels for 3T= are nor applicable at a TPN cusctrstian of TO pon (gasoline) or 100 ppa Cdimei)- <br /> VI. STAFF RECCMMENOATION/=CLl1SIm1 ,-r 1..'. -.- C�' �• •rL(iyt�Q� p. L�U��(X�1"r�'�'-�`' <br /> 1. Are 3TX 3 E or ,PH Carcatracions > ALLawadle Lavels I?esl <br /> i <br /> 2. Recommend Site Closure)Yesl INo1 II•'If Yes, Refer cc Site Mirigarion for °valuation , <br /> VII. REVIEW EVALUATION • TO 3E CafPL_cTED 3Y A WERVISOR/SENICR <br /> i=VGR WITH STAFF RECf7MfEM0ATTCM FOR CLOSUREIYESI NSI (REFERRED TO SITE 142T2GATTOM rOR --VALUATIONIYESI INa( l <br /> OAT'c REFZREDI / / !GATE CLOSURE LETic.Q MAILED( <br /> NAME OF <br /> E4ALUATCRI <br /> EH 33 30 (UGi VKSHT)\5/90 <br />