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SAN 10AGMY NTY PUBLIC HEALTH SERVICES/ENVIRCNMENTAL HE - "1 3 WISICH s <br /> (. `/ T ':ORKSHEET POR SITE Q65UAE �lALIJATICN OATEI <br /> NAME OF FACILITY �d� .S OG n IsYE=s CCDEj a 1 , <br /> 1AOORESSI a S (TANK l.0 <br /> (TANK SIZE1 /0 0 r� IFUEL TYPE( <br /> (I. GENERAL SITE HISTORY <br /> � (s remit current?(Yes Nol Permit S - (Facility Status Coder ( locc-SaiL/I,SN Cant Yes <br /> l IMe <br /> �Nuheer of Tanks at faciliryl Age of Tanks(it oval.lable)1�' lType of rank lSteeLFbrgll ISngll Ouall <br /> TANK HISTORY <br /> Vas Tank tested?lyes X No Fai Led precision test ?ITesl lNol IIf yes, give date(s)1 / <br /> ;as a repair made to :he tank syszm? Yesl Nel Iif yes, what was mT,i redo <br /> !':as reoair done under inspection?I Yesl INal IVere soil S=(es analyLedl l Yes) INaI IETXEI ITiN-GI ITPN 31 lPb/S <br /> .Type of tai Lure/discharge) lcatastroph i el (long-tens Leakage) IoverfilLl Iunfmwr+I lacier: <br /> I <br /> LV. RE!OVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE OEi AILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> :Sail Saacles ReceivedI Teal lHo IOepth to acarid alter DIRef/Year{ (5�6 (Average Arcual PrecipitatianlA=114. 110-251 <br /> Cn-Site 4eLL(s)IYesl Nool Number i TYpel Irrl 10=1 IPunl <br /> S Scare S Sore S Score <br /> !Oistance :o vel L(s) from ramal ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> a if 0 if a if <br /> �L R Condiciah R cz ition R co; ition <br /> IV. Site Feature - Leaching PoCaMciai Analysis Sd —I — 37 �is set is .pot = is pot <br /> IMinis Death :0 3r=,,,uatar from j1e SaiL iaaole (feet) l l >700 I 15t-7C0 I 1. 25-i0\t <br /> 1Factures in subsu"ace (applies -a foothills or seuntain areas) ' Q ` None 1 1 URknawn 1 1Present <br /> Average AnnuaL Precipitation (inches) ()ooeuxl s10 l 9 110-25 laa000ecc 25-4.0\2 <br /> !Man-Made anduits which increase Verticzl migration <br /> iar Leachate (i.e., septic nal , water we(ls, pones) I I Norte i Unkr:own I (Present <br /> Unique site features: Recharge area, coarse sail, nearhy welts. Narhe A L anal ast More than <br /> one <br /> iC)L10111 craw»Toru Patxrs <br /> �Sanr;let:: (H T X OR E) .RANGE OF TOTAL POINTS 4.9 pts or mare I 4.1 - ca pts 1 pts or Less <br /> �K-! Sial( 3 T X I E T X <br /> •� K + u � A)b NAXI)NNN ALLOMLE 3-r-X-? LEVELS (PPM) tl ia� SOI 50 .3 3 T.I 1. l xa\3 <br /> Went INE 1000l top 10 <br /> "•f'�i �sT✓ IMAXIMINI arhDWANE TPN LEVELS (PPM) 1 <br /> 1 tom' _ yet X �j'•' IDIOM 1 10,a00 I Ima t I 100 <br /> F•COTNOTES: &I " Tf dpetmented sail and/or ground water ontaminatim is preset?, cba the Leading pctetttaL <br /> analysts. (i.e., site is currently at LGT Contamination List for snit or ground water.) <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth =5 ft., do not use table. <br /> \Z if precipitation is > 44 inches, sore 0 paints. <br /> \3 Lavets for 3TXdE are not applicable at a rPH o,,, Cration of 10 ppa (gasoline) or 100 ppa (diesel.). <br /> VI. STAFF REMMMENOATTON/CONCLUSION R-) /'f c''+ <br /> 1. Are RTX 3 E or TPH Concentrations > ALLowebte Lavels I'ynl IN-IX I ��' " �Z aJ / J�41� <br /> ks <br /> 2 Recommend Site Ctosurel Yesl lNol )< �Tf Yes, Refer to site Mitigation for Evaluation A Q S <br /> �� <br /> VII. REVM EVALUATION - TO 3E CMPLE <br /> M 3Y A SUPERVISOR/SENIOR WK �GUL' J`%itis-rte' <br /> C.VCJR VITH STAFF 3ECCWeMTTON FOR C.090LEjYESI N01 IRE-ERRE TO SITE MITIGATTON FOR EVALUATIOMIYESI lNOI Ii <br /> DA—.. REFERREai KATE CLOSURE L—FrE.R MAIM( 1 <br /> NAME OF <br /> EVALUATCRI <br /> SH 23 30 (UGTWSHT)\5/90 <br />