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SAN :OAaUIN C PUBLIC HEALTH SE.RVICS/EHVIRONMEYTAL HEAT 'VISION <br /> I. 't=T WORKSHEET FOR SITE GOSTUREE c/ALUATION �� DATE' <br /> INANE OF FACILITY ?QMH /f , - r�4 '-7--�L//' , ISVF=S CME <br /> I 6�0 c j(G2/{�17iG1 }7? T (- =I.3 , ' /s <br /> ADDRESS! v TAN yKiD C <br /> jTANK SIZE( /J , CoV IFUEL irPEl D� �A/�✓+Ks r /' i / �� <br /> (I. CENE.RAL SITE HISTORY LJ <br /> Cs -emit current? X INa1 (Permit 3l Facility Status Codeb. 1Doc.Sai L/GW Cont)Yell meI <br /> .Nuhcer of Tanks at facility) - (Age of ianksOf availaote)I /7b4nITYpe or Tank Seel h(I Fbrgll Sngll auaL1 <br /> .... TANK HISTORY <br /> Was Tank cested7 Yes XNe1 (Failed Precision :es: ?IYesl INo✓�1[% yes, give date(s)1 <br /> .as a repair made :o :he :ank sYsrm?l7esl No If yes, vhat wasrepai reGtld�ra`iu .�C{� c ���,/� Q ✓ <br /> '':as repair done under inspection2iYesl INoi Were sail sales analyzeG?jyesl INa1 BTXEI 1TPH-g1 1TP4JI hlPb/OBI I 1 <br /> 'ype of !tai lure/disciargel lracasmaoniel 11an9-termh Leakage) Iaver-Pi ll vdawwl Totter: <br /> iV. REMOVAL HISTCRY (ATTACH INSPECTION REPORT FU Siie DETAILS/COLL:C DATA FOR LEACHING POT'EHTIAL ANALYSIS) <br /> 'sail Sahmles Received!y es x <br /> No iDepth :o Ground Water l56IRef/7ear Q/ jAvemge AmuaL Precipit3tionlA=I14 110-251 <br /> Cn-Size Wei l(s)IYes1 Not Number3 iypei Irr1 Ono) IPupi vV/ <br /> 5 Scare S Scare 3 score <br /> Oistance ;o We(ls) from Tankft: C 10 pts C 9 pr C 5 Pts <br /> D if a if a if <br /> i cs+ditim 7 coraitim R condi tion <br /> V. Site Feature - Leaching PeteriaL Analysis = is .mc is net is me <br /> Minimum 0eptn ;o groundwater frpa the Sail Saeate Cfeet)50- I i >Ia0 1 i51-100 L-i0\1 <br /> "•-Ictures in subsurface (acpl Hes :o faaNills or nountsin areas) 1 i � `Ione I Unknown I Present <br /> lave.^age Annual Precipitation (inches) IsmaXl <10 I 9 1 10-25 laxul�l S-4a\2 <br /> '.Man-Made acnduics 'which increase •anti CHL nigratim <br /> of leachate (i.e., septic systems, rater veLLS, Pons) I I Norte I Unknown IPresert <br /> iunirue site features: Recharge arae, coarse sail, rear=y w 1ls. I I At least) Noce than <br /> XZtSXx None aaanye <br /> COLLTN TaTALS>»TOTAL POINTS I/ (J I I I L-� la 2 J u <br /> SIsaaele ResuL;: (3 T X OR _) BARGE OF -OTAL POINTS 49 Pts or .mr'e 41 - :3 pts :a pts <br /> P3 Ar S3 (-"DNNaSP3C;. p ;j T I z I E 3 T ` z I E. <br /> �I= w 3 MAXI" ALLOWABLE 3--,-X-- L--MELS (P914) 1I M50 Sa 3 I 1. 1. NPV <br /> sample xesutt:s F'3 (7T U� = I b GAsaLINE 1000 1 tea 1 to <br /> Sf J/f Y L3 (a r� MAXIMT A TPH LEVELS (PPM) <br /> TO,= I lana Ha <br /> S�F•ATNCTES: —If docmmted sail and/or grPtind water ==amination is present, do not Delete the leaching <br /> anetysis. (i.e., site is =rrntLy on UGi Cacaninatim List for soil or ground nater.) <br /> \1 tf death is > 5 ft- and c Z5 ft., sere 0 points- If depth =5 ft., do not use able. <br /> \2 If precipitation is > 40 inches, sore 0 Points- <br /> \,3 Laveis for 3TXZE are not appticsbte at a 7x Ca1narrtrat1on of TO ppm (gasoline) or 100 ppm (diasei)- <br /> i <br /> VI. STAFF RECCa1MEM0ATI0N/CCNC115ION I X auI io <br /> I- Are 3TX 3 E or TPN Concentrations > ALlereble Lavels I-Tesl Na, („ <br /> 2. Recommend Site Ctosumiyasl INaI Irlf Yes, 3efer to Size Mitigation for Evatuatian <br /> VII. REVIEW EVALUATION • TO 3E CTP(-Ef® 3Y A SUPSMSCR/SEYICR <br /> =.11C1R VITH STAFF RECCMMEWATICB FOR CLOSUREIYESI INOI REFERRED TO SITE .MITIGATION FOR EVALUATIONIYESI INaI I i <br /> DATE RE EiREDj DATE CLOSURE )_TER MAILM- <br /> NAME OF <br /> EVALUATVRI <br /> Ex 23 30 (UGTWKSHT)\5/9a <br />