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, Ic)b ir-��- o Oq 03 <br /> SAN .:CACUIX C PUBLIC HEALTH SERVICE'S/ENVIRCNMEHTAL HEAL VISION <br /> 1. WORKSHEET FOR SITE CLOSURE EVALUATION DATE 7 3—9 g' <br /> NAME OF FACILITY 1 / D r ce— ISWE=oS =F1 a3 <br /> (ADDRESS( ITANK ID 41 I <br /> (TANK SIZE �D1�� (FUEL TYPE( jn� Q/ C eQad-, U) <br /> I1. GENERAL SITE HISTORY <br /> IIs permit current? Yes 1XI <br /> NoI IPamir d - IFaciliry Status Cede O'IDac.Sei L/GW Cons yea Ixi No <br /> INunber of Tanks at faciliryl 13 (Age of Tanks(if avai table)I 3(4aJType of Tankl SteelX Fbrgll SngII Dust <br /> :II. TANK HISTORY [,^5 I �— <br /> :Was Tank tested?IYes "41e 1Fai Led precision test ? Yes INoI IIf yes, give date(s)1 <br /> �'4as a repair made to the tank system? YesNo if yes, what was repaired7l <br /> ;Was repair done under inspectian7lYes1 INoI (Were sail samples analyzed?lYes1 INoI MEI 1TPH-G TPH-0I Pb/EDB( <br /> "ype of failure/dischargei I catastrophic I hong-terns Leakagel IoverriLLI Iunknovnl Iother: <br /> LV. 2EMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples ReceivedlYesl Ne (Depth to Ground Water (Ref/Year) Average Annual Precipitation A=114 110-25 <br /> ICn-Site Well(s)IYes I meNumberNumber & Type IrrI IOam IPWbi S Score S Score S Score <br /> !Distance tc Wei L(s) from Tankl ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R condi tics R condition R condition <br /> IV. Site Feature - Leaching Potential Analysis is met _ is met E is met <br /> Minimus Depth to groundwater from the Soil SammLe (feet)w IQ.- I >100 1 151-ICO 1 '5 1. 25-50\1 <br /> F-actures in subsur,'ace (acplies to foothills or �tain areas) 1 NoneI 1 Unknown 1 (Present <br /> Average Annual Precipitation (inches) lxsuxxl <10 9 1 t0-25 Ixxxxxxx 26-40\Z <br /> !Nan-Made conduits which increase vertical migration <br /> sof leachate (i.e., septic system, water wet Ls, ponds) ( 1 Nate Unknown 5 Present <br /> jUnique site features: Recharge arae, coarse sail, nearby wells. 9 At Least More than <br /> 1 xz:oco:I Norte 1 I we one <br /> iCOLUMN 10TAl5»>iCTAL POINTS + U I I :NA\,3 <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or mare 41 - 48 pts pts or less <br /> N x =a,7 �oS X = ( i1 MAXIM)M ALLOWABLE 9-T-X-_ LEVELS (PPM) 1 31 50 50 50 311. 1 <br /> Sarypis Rasy(L PpGeralJMAXIMLIM ACLOYABLE TPN LEVELS (PPM) WINE 1000 100/S_ �.� TPH DIESEL 10,000 1000 100 <br /> r. TNOTES: !I"f pdoeemc�tuei sail and/or ground water contamination is present, do not c000lete the - ng po <br /> ' � figpQ�Ot1'\�1Q,yt�r�p analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> ) 11� lAo is > 5 ft- and < 25 ft., score 0 points. if depth < 5 ft., do not use table. <br /> I� ^ �1 If precipitation is > 40 inches, score 0 points. <br /> 1 \3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gesatine) or 100 ppm (diesel). <br /> VI. STAFF RECCMMENDATION/WNCLUSION Not Ti,S to14 M7',6 EI/ <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels -Ya Ix <br /> No <br /> 2. Recommend Site Ctosure Yes 1Na � If Yes, Refer to Site Mitigation for Evaluation V <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SEYICR <br /> CCNCUR WITH STAFF RECCMMENOATION FOR CLOSUREIYES1 TC1 (REFERRED i0 SITE .MITIGATICN FOR EVALUATIONITESI q161 I <br /> GAME REFERRED / / IDATE uCLOSURE LETTER MAILE01 <br /> NAME OF <br /> EVA WATCR <br /> E:i 23 30 (UGTWKSHT)\5/90 <br />