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SAN ..OAW(H COJNTY HEALTH SERVICES/£HVIRCHME4TAL HEALTH DMO ATE I --� <br /> UGST 4CRKS4EET FOR SITE OLOSLRE -VALUATION <br /> NAME OF FACILITY ���'���G/f.., SbLf' Cy I3WEEPS CCOE C�'L <br /> .AnORESS s�� /�C (�- l,r ANY [0 X <br /> �IANK SIZE 6 ��0 UEL TYPE 6L <br /> GENERAL SITE HISTORY <br /> Is permit current? es a ermic X acility Status Code oe.Seil/GV Conc es a <br /> Nunber of ranks at facility ge of Tanks(iI avaiIable 1 S ype of Tank tee) Xfbrgl ngt Oual <br /> '!. TANK HISTORY <br /> ;as Tank tested? es a ailed prem ision test 7 es a If yes, give date s) <br /> Jas a repair :rode to the tank system? es No f yes, chat was repaired? <br /> has repair done raider 111:11!1:' :111 es o ere soil samples analyzed? es o iXE I PH•G I PH-0 b/E08 <br /> Type of failure/discharge atastrcchicl long-term leakage ) verfilt known cher: <br /> REMOVAL HISTORY (ATTACH INSPECTION REPCRT FCR SITE DETAILS/COLLECT DATA FOR LEACH(HG POTENTIAL ANALYSIS) <br /> ioiL Sana les Received Hes o epth to Ground ''dater I of/Year ver age Arcual Precipita cion � = CP110-25 <br /> -Site ''dell Cs7 es o tater t Type Irr IX° b S core Ti�s �t <br /> S core <br /> Jis:ance to Well(s) from Tank ft; -ft; ft C 0 pts PCs <br /> 0 if 0 .f <br /> R orditim R crdition <br /> �- Site Feature • Leaching Potential Analysis "c is met E �s met <br /> I <br /> 'tinimtm Oepch to greusdwater from the Soil Sample (feet) >100 1-1C0 25-50\1 <br /> =ractures in subsurface (applies to foothills or mountain areas) None ( Unknown resent <br /> Average Arcual Precipitation (inches) zxxz <10 9 10-25 axxxxz 26.40\2 <br /> man-Made cor6iits which increase vertical migration Vme Unknown resent <br /> of leachate (i.e., septic systems, water wells, perds) <br /> t . I <br /> Flai ore than <br /> yve site features: Recharge area, coarse soil, nearby wells. At leasone one <br /> � zzzx None <br /> COLUMN TOTALS>>>TOTAL POINTS ' <br /> -amble Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> 4 T X E B T X E <br /> MAXIHLH ALLOWABLE B-T•X•E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. HA\3 <br /> Sample Result: <br /> SCI INE 1000 100 10 <br /> AXI MIH ALLOWABLE TPH LEVELS (PPM) 100 <br /> TPH IE SEL 10,000 1000 <br /> COINOTES: ...If documented soil and/or grourd water contamination is present, do roc complete the Leaching potential <br /> analysis. (i.e., site is currently on LOT Contamination List for soil or ground water.) <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use cable. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTXSE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 Fpm (diesel). <br /> :. STAFF RECCFWEHOATION/CCNCLUS ICN <br /> 11. Are BTX 1. E or TPN Concentrations > Allowable Levels Yes o <br /> � 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> 1. REVIEW EVALUATION - TO BE CCMPLETEO BY A SLPE1VISCR/SE4ICR <br /> -OHCJR VITB STAFF RECCNHE40ATIOH FOR CLOSURE YES 0 EFERRED i0 SFTE HIiIGATICH FOR EVALUATICN HES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER :AILED y / <br /> WE Of <br /> :VALUATOR <br /> EN 23 80 (UCNXSHT)\5/90 <br />