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SAN JaAQUIM C IUrY PUSLIC 4EAL7H SE.RVICS/E4VIRCNMEMTAL HEALTH aIVISICN <br /> 1. i 'JOR-KSHHHEET_FOR SITE CLOSURE EVALUATION CATEI Z7Z G I'1 <br /> INANE OF FACILITY -JL /C ISYS=aS C9EI A - / .S. �/ J <br /> AOORESS 6&60TANK M <br /> � ' /�//�1/GrY!/U <br /> (TANK SIZE( �4000 (FUEL TYPEI �J2I <br /> II. GENERAL SITE HISTORY <br /> � Yes X NCI IPecoit ,I (Facility Satus Cadelo �,IDac.Sai L/Gd cmtlYesl INC <br /> Is =ernit c�rrmt?( I <br /> .4u oer of Tanks at facilityl 7 (Age of Tanks(if avaitacle)i /,,j Type of r.icjStaeli��]�yiFbrgLl ISngII OuaLI <br /> „I. TANK HISTORY , <br /> Vas Tank :esied7l Yes I vN.1 IFailed precision :est ?IYes I INaI If yes, give date(s)I <br /> as a repair made :a the tames systaW I7esI NaI If yes, enol ra3 repot reeY!I ,� CG/dZLl2S�2.('xF pye SS6/u- <br /> I'Jas reoair done under irrtpectiontl Yesl INaI Were soil Samles analyZW? Yesl INaI BTXEI I7744 ITP4]I IPb/EDB( I ' <br /> 'ype of failure/disciargel otascropnicl hang-cern Leakage aver-fi 111 Iunciwnl Iather: <br /> 711. le-.CVAL HISTORY (ATTACH INSPECTION REPORT FCR SITE DETAILS/COL_—= OATA FOR LEAC1ING POTENTIAL ANALYSIS) <br /> 'i Soil Samples ReceivedlYesl INaI IDepth to Ground Water 156 Ref/yearl Y6 (Average Arrwl Preei pi Roti an IA=114 I10-S <br /> ICn-Site 'JeLL(s)IYesl INaI IHunser 3 Typel Irrl I)=I IPesl <br /> S Scare S Scov3 Score <br /> 710 is:ance :a VeU(s) flan Tarticl ft; r C 10 pts C 9 pts C 5 pts <br /> • 0 if O if 0 if <br /> .R (condition R corlsician .R condition <br /> IV. Site Feature - Leaching PotmitiaL Amlysis - `'C is Met E is Car ? is set <br /> (Minimax Oeoth to groundwater from cone Sail Sa to (feet) I I >iQQ I 151-100 I 5-30\i <br /> IF-jc:ums in subsurface (applies to fwOiLls or .:contain areas) ' sane l l Unknown I IPresm <br /> Average Annual Precipitation (inches) Ixssndc� <10 l 9 i 10-5 1modooCcI <br /> 'man-Made conduits which incIe verticoi aigration <br /> of leachate (i.e., septic systems, water mils, ponds) I I .lone I j !)nkraun I 5 Presarc <br /> Unicue site features: :Recharge ame, coarse sail, near-y xILS_ I I I n At Least) Marc zhan <br /> :wouX sari l•' dna' we <br /> COLUMN TOTAL.A»TOTAL POINTS <br /> SaancLe Result: (S T X OR E) RANGE OF TOTAL POINTS L9 pts or mer_ I +I - :a pis I or less <br /> 371 T I 3 T X I E <br /> K? U) MAXIMUM ALLCUABLE 3-T-<-= LEVELS (PPM) 1 50I X 50 50E .3 .3 1. t_ NA\3 <br /> SAW ole .Result: /lf /1 GASOLINE 1000 I 100 I 10 <br /> "rK3 F� .-00C. <br /> �( 3G= '" v MAXIMA LLOAULZ TPN LEVELS (PPM) <br /> TK TPH D DIESEL 10,acc I TWO Soo <br /> P•CCTNOTES: If docemlted soil and/or ground "ter cdntminatim is present, do not co- Leta the Leeming pacenciaL <br /> analysis. (i.e., site is currently on UC Contamination List for sail or growls eater.) <br /> \1 If dem)L is > 5 It. and < 25 ft., score 0 points. If depth �5 ft., do mt use table" <br /> \2 If precipitation is > 64 inches, score 0 points. <br /> \3 Levels for 3TXSE are not applicable at a 71134 concentration of 10 ppm (Ga, Una) or 100 ppn (diesel)_ <br /> VI. STAFF .RECCMME40ATICN/CCNCLUSIOM j -&�'j a ';yes, <br /> 1. Are 3TX 3 E or TPN Camencrationa > ALLawacte Levels I'Tesl INoI <br /> 2. Recamend Site C:asurclTes�INol 'If Yes, Refer co Site Mitigation for Evatuatfon <br /> VII. REI/LEY _VALUATION - TO 3E COMPUTED 3Y A SUPERVISOR/SEMICR <br /> CCNCJR VITH STAFF RECCMMENOATICM FOR CLOSUREjYESI INaI IRErra- m ra SITE .4ITSGA7IOM FCR FVAWATIONIYESI INOI i <br /> i <br /> DA78 3EFERREDI / / (GATE CCMRE L-7E4 MAIIMI / / <br /> NAME OF <br /> EVALUATOR <br /> E4 Z3 30 (UGTUKSHT)\:/90 <br />