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SAN ,10AOuIN W PUBLIC HEAL X SERVI iRONMEHTAL HE �IVISICN <br /> "xsHEET FOR SITE CLOSURE EVALUATION / DATE( <br /> .ME OF FACILITY . S �/ SWEEPS CODE <br /> ADDRESS S `�B" v/c� l_� TANK ID YI <br /> TANK SIL Z G FUEL TYPE <br /> II. GENERAL SITE H15TORY <br /> Is permit rurrmt7 Posh Mo Permit R) - Fncility Status Code DOC.SOWC61 Cont Yesl No <br /> Number of Tanks at faciLitY IAga of Tanks(1f available) Type of Tank l Steel Fbrgl) JSngL1 Dual <br /> III. TANK HISTORY <br /> Was Tank tested? yes No I Failed precision test 7 Yes No If yes, give date($) <br /> Was a repair made to the tank system? Yes so If yes, diet.Was repaired? <br /> Was repair done under inspection? Yes (NoI Wen soil samples analyzedtlYes INo BTXE TPN-G TPX-DI IPb/EDB <br /> Type of failure/discharge) catastrophicl ILong-term laakage overfill unlman other. <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FCR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received 7esl INo (Depth to Ground Water Ref[Year <br /> /�; C,� Average AmnUnl PreeipitatimlA• 14 10-25 <br /> On-Site WeLL(s) Yes No (Number L Typef Irr IUom Pub S Scare S Score S Score <br /> Distance to WeLI(s) from Tank) ft; ft; ft C 10 pts C i pcs C 5 pcs <br /> 0 if 0 if O if <br /> R condition R condition R cacti ti an <br /> v. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> Mi nihhwh Depth co 9ropdwaier from the So Sade (feet) I ,100 I 51-100 I 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) <br /> None I I Unknown I IPresen <br /> Average Annual Precipitatim (inches) Xz�ucu <10 9 10-ZS Ixamal 2.5"40\2 <br /> Men-Made conduits which increase vertical adgntion None I Unkthohat (Present <br /> of Leachate (i.e., septic systems, voter tenet ls, porc'-s) <br /> p coarse soil, nearby Wells. At least Mnnc than <br /> Unique site eacures: Recharge area, xxxx« None one one <br /> COLUMN TOTALS»,TOTAL POINTS I. <br /> Sample Result: (3 T X OR E) RANGE OF TOTAL POINTS 49 pis or mare I 41 - 48 pis I 40 pts or less <br /> MAXINUM ALI:IWLE 3-T- -E LEVELS (PPM) 1 SOI SOI 50 i .3 I.3 1. 1. I NAV <br /> Saapte Result: <br /> GJLSOLINE 1000 160 I 10 <br /> MAXIMUM ALLOWABLE TPN LEVELS (PPM) 100 <br /> T➢N DIESEL 10,000 1000 <br /> ... Water contamination is present, do not comlete the Leaching potential <br /> FOOTNOTES: It don analysis. <br /> ( .,_, s ground <br /> ane Lysis. Ci.e_, site is currently m UGT Cahtamination List for soil or ground "ter.) <br /> \1 If depth is > 5 ft. anti < 25 ft., score 0 points. It depth a5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for STXbE are roc applicable at a TPN ooneentraiton of 10 ppm (gasoline) or 100 ppm CCt esel). <br /> VI. STAFF RECOKME1D)ATION/CONCLUSION <br /> 1. Are BTX b E or TPH Cmcentracions > ALLaable Levels *Yes No <br /> 2 Recommend Site Closure l7es No �,It Tes, Refer to Sits Ni ti gatim for EvalWtiml <br /> VII. REVIEW EVALUATION - TO 3E COMPLETED 37 A SIPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECLX9HENDATIOM FOR CL65flE(YES NOl (REFERRED TO SITE MITIGATION FOR EVALUATICNIYESI NOI <br /> DATE REFERRED( / / (DATE CLOSURE LETTER MAILED( / / <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 • <br />