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SAN 4CACUIM =lurY PUBLIC 4EALTH SERVICES/EMVIRCNMENTAL HELLiH OIVISICH <br /> 1. „,'''111 'AMME:i FCR SITE (--QM <br /> RE EVALUATION CATER <br /> !NAME 7F FACILITY pl /C,. ISLtE}5 C. I A 3_I.53J <br /> ADORESSI 600 4 . jt([Q///ffjL4'yrj� (TANK iD .13 1_,53 (V/,�_f, <br /> TANK SIZE! Q.nQ D (FUEL TYPE! w/ f'C � J <br /> W i <br /> II. G-cMEAAL SITE HISTORY <br /> FIs =emit current? Yes X INaI Ipermit iI - !Facility Status CodeloJ— IOac.SoiL/Q Cant Yesl NoI <br /> Auneer of Tanks at facility! !Age of Tanks(if available)! /'Y IType of rankisteeLl IFbrgll Sngll OuaLl <br /> ..,. TANK HISCRY <br /> Was Tank tested7l Yes No IFailed Precision cess ?IYes! INaI x IIf yes, give dace(s)l <br /> ;as a repair made :o the :ank syszesrtl Yes! .McI IIf yes, wnac as redairea?I <br /> leas repair done under inspection?I Yesl INo! Were soil sascites anaLy7.ee?IYes) INC BTXEi !TPN-GI ITPH-DI Ipb/EDBI <br /> -yoe of failure/discharge! Icatastrapnicl (Long-term Leakage) overfiLdl i t Iaaher: <br /> :V. iE'SCVAL HISTORY (ATTACH INSPECTICN AEoORT FM SLiC DETAILS/CCU_'CT DATA FOR LEACHING POT-ENTIAL AHALTSIS) <br /> :Sail Samples 3eceivediyesl INal !Depth :T Oraund gated IRef/Yearl !Average Artsnl 7recipicaticnlA=I14- 110-Z5I <br /> Cn-Sita 'Jell(s) Yesl No !Number i Type! Ir'! IOrmi Ipwl <br /> S SCOre S SC re3 Score <br /> D;stance co Jell(s) from Sarecl K: C 10 pts C 9 pts C 5 Pts <br /> C if C if 0 if <br /> .I Codi Lien I C3idition A CC(ditlan <br /> IV. Site Feature - Leaching Potential Analysis _ �is Tet is Pet is Mc <br /> Minimm Depth ca groundwater free '-'se Sail Sasule (feet) I I 'WO I 151-100 I I Lc-50\1 <br /> !,-,nctJres In SUbaurface (aaptles ta foothills or m amain areas) / D Mane I I Unknown I !present <br /> Average Annual Precipitation (inches) I I <fo I 9 110-5 Ixzmcc(I Z5-40\2 <br /> '.Man-Made ancui cs which increase vertic*L .Tigretiad i <br /> of Leacfate (i.e., septic systems, water wells, ponds) I I Anne I Unknown present <br /> Unique site Features: Recharge area, parse sail, nearby wells. I I AC Leas:! More than <br /> )COCdtx None <br /> one one <br /> COLUMN 7aTAL9»ICTAL POINTS IID I I I i✓JJ e JF <br /> S K53Nukz: 3 N D _) RANGE OF TOTAL POINTS 49 pts or Tar_ :1 - /.a Pts :a pts or less ! <br /> rrS All � � Iic51E 3 Txi <br /> 7K J NAxI)alti ALL.LYABL£ 3-r-x-? Lc"vas cppM) i 501 50 50 -3 i. Na�3 <br /> Sande R ulz: GASOLINE 1000 I 100 I 10 <br /> �tyL� MAXI <br /> rpm <br /> TPX LNE'_s CPPV) <br /> IV✓TpN DIESEL 10,000 1000 I 100 <br /> FrCTNCTES: ^'If dacmented soil and/or ?rmaid water concaminatian is present, do not csclete :21e ing potential <br /> analysis. (i.e., site is currencty on UM' Canmminatian List for sail or 3rosnd wcer. <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points- If depth =5 Pc., do not use table. <br /> \2 If precipitation is > 40 inches, sore 0 Points- <br /> \3 Lavets for 3T%ZE are not aapliClble at A TPR omcentrotion of 10 ppa (gaso(ine) or 100 ppm (dieaei). <br /> YI. STAFF IE{':1IME40ATIOM/gICUSIOH `S-rO(-KIDI 1'Q-Plat - yluQ CPC /I <br /> t. Are 3” i Ear TPN Carmtiratians > Al lowabL.e Levels I-1'esl No <br /> K e �r,ti.�t ems,17"a ule <br /> 2. Aecommeid Site CLasureI Yes Nal 1i-'If Yes, Refer m Site Mitigation for .vaLuaci and ` & <br /> VII. 2E'/TESL EVALUATICH - TO 3E C LETED 3Y A SIIDERVISCR/SEHICR <br /> CONCUR VITH STAFF i£CCMMEVDATICM FCR CLOSURE!YESI INOI RErEgREO TO SITE MITIGATICH FCR EVALUATICNITESJ !MOI I 1 <br /> DATE AEF=4REDI / / (DATE CLOSURE L_T,'i .MAILMI <br /> NAME OF <br /> E'/ALUATCR I <br /> EH Z3 30 (UGTUKSHT)\5/90 <br />