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SAN 4ACUI1PUBLIC HEALTH SERVICES/EXVIRCHMENTAL HFALi VISION <br /> I- _ 1' ''xRKSHEET .FCR SITE CLasURE EVALUATION 0 GATE( /2—7 <br /> (NAME OF FACILITY <br /> i;7 ISSIE= 5 CCOEi <br /> IAODRESSI r/ �, j/ ITANK ID I <br /> TANK SIZE � FUEL �PEi ✓ j <br /> II. GENERAL SITE 4I STORY <br /> III <br /> : (s permit current?IYes XHO (Permit 3I - IFacitiai <br /> / Status Cel Q�IDcc.Soi L/Cj Cant Yes Ne <br /> ..Y m er of Tanks at fact Uryl �;L_ (Age of ianks(if available)( (Type of ianklSteeLI IFbrgLl ISngLI OuaLI <br /> TANK HISTORY <br /> Was Tank rested7l Yes INoI (Failed precision :est ?IYes( Nol IIf yes, give aace(s)I <br /> :as a repair nace to the -tank system?lYesl NO; Itf yes, what was repai rec? <br /> ,:as repair done ':neer inspection?lYesl NCI Iuere soil samotes analyzed?IYes( Igo HTXEI I?H-GI ITPX]I IPb/oE <br /> 'ype of failure/dischargeI Icatastrapnicl (tong-team Leakage) Ioverfilll Iu..known) lacier: I <br /> 711. REMOVAL HISTORY (ATTACH tHSPEC,ICN REPCRT FOR SITE DETAILS/COLL<CT DATA FOR '°ACHING POTE4TIAL ANALYSIS) <br /> Smit Samol es 7ecei vedlYesI II I <br /> Noffi w <br /> DepGround Water irXt�IRef/Yearlg�( Average ArnuaL 7reeipi tacianlA=I14 I1(1-SI <br /> ICn-sire 'aet((s) YesI INoIXI Number i Typel IIrrI IOaa} IPuil <br /> a (Score S Scare "a Score <br /> IDiscance ;o 'Jet L(s) from TanklC 0 ;Its C 9 pts C 5 pts <br /> ft. a it 0 if 0 if <br /> R Icorldi tier 7 Cardi tion R condition <br /> V. Size Feature - Leading Pasemiat Analysis IIs :nee = is net is met 1 <br /> Minimum Oepch to greuncwater from tie Seil "aanole (feeeet) I I aIca I 151-ICO I I- 25-50\1 <br /> IF--C-1-Wes in subsurface (acplies -o rootnit(s or ro. lain ares) I / o I Rene I Unknam I (Present <br /> (average Annual Precipitation (index) Ixzxxxxi "a I 9 110-25 xxxxxxxi 25-40\Z <br /> 'Man-Mace circuits wnici increase ver-Teal migration <br /> �cf leacnate (i.e., septic systems, water welts, ands) I I None I 7 I Unknown I Present <br /> .Unique site features: dedarge area, coarse sail, nears/ �eLLs. I I ^ I AL least) More than <br /> 1 zs:oLtt Nara (•II ane ane <br /> i <br /> j f� i <br /> MLU14N iOTALA»TOTAL POINTS 16 I ,2 7 I } <br /> i Sancle 1.11LZ: (S i Xy�OR i) .RANGE OF TOTAL POINTS149 Pts or mor-_ I 41 - 4d pts 4a pts or Less I <br /> I�TFU2� <br /> -An In) <br /> I ;I TIXlE I ; ITI XIC <br /> -T k f S R �}p MAXIMUM ALLOWABLE 3-i-%-? L-'VES (PPM] t n7 00 50 3 ,3 t. 1. NAV3 <br /> Saznuke .orst S, - �,+ n. I GASOLINE 1000 I 100 I 10 <br /> lU1V MAXIM)M ALLOWABLE TPX LEVELS (PPM) <br /> TPH DIESEL 10,MCI I 1000 I 100 I <br /> .FOOTNOTES: "•If documented soil and/or ground nater contamination is Present, do not oamnl eta tie ing potentiaL <br /> analysis- (i.e., site is .Turrercty an UGT Contamination List for soil or grausd wat <br /> \1 If depth is > S ft- and < 25 It., scare a points- If depth c5 ft., do mt use table_ <br /> \Z If precipitation is > 40 inches, sere 0 points_ <br /> 1 \3 Levets for 3TX3E are mt applicable at a TPN ccncmtrati an of to ppe (gasoline) or 100 Fpm (diesel). <br /> VI. STAFF RECCMMENOATION/MXCLUSICN <br /> S-tr,cK�� le �.,Qu,.,.AAe..��A&&' <br /> (o <br /> 1. Are 3TX 3 E or TPM Concentrations > ALLowabte Lavets I^es (Nei <br /> 2 mTa� Te^(3< <br /> Recaumuend Site Closurei Yesl INeI . >I. Yes, tefer m sire Miil4ation for Eraluaci an C�0 �Kq- <br /> VII. REVIEW EVALUATION - TO 3E C71PL-ETED SY A SUPERVISCR/SENICR <br /> IC^NGR WITH STAFF RECOMMENDATION FOR CLOSUREIYESI !Mai IREFamTO I Ic Mai I I�/ fG�• <br /> OAT"a 7EFZ-RRE41 / / KATE CLOSURE L-- is MAILED( <br /> i <br /> NAME OF <br /> EVALUATCRI <br /> E4 23 30 (UGTWKSMT)\5/90 <br />