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SAN 4AQUIN CCUNT" ',LZC HEALTH SERVIC=5/E4VIRCNHEYTAL HEALTH 0 ICN <br /> UG AYSHEET FOR SITE CLOSt;RE EVALUATION ATE — <br /> IAyE OF FACILITY SWEEPS CCOEZV � <br /> nOR£55I �ac 1� W TANK 1Q 3 - l'8 2 --lyV <br /> ANK SIZE 5 r)O UEL TYPE ? ,e <br /> GENERAL SITE HISTO <br /> s permit current? + es OL <br /> ermit 43 �(� � acility Status Cade oc.Sail/Gm torices o <br /> Vrt)er of tanks at facility ge of Tanks(if available) ype of Tank- reel Fbrgl ngl Dual <br /> TANK H:STCRY <br /> ns Tank tested? es o ailed precision test 7 esa if yes, give date(s) <br /> as a repair made to the tank system? es 4o f yes, what was repaired? <br /> ns repair done raider inspection? es a ere soil samples analyzed? es o TXE PH-G PH-0 b/EQ8 <br /> r�� e G <br /> ype of failure/discharge atastrophic long warm leakage vertill nknown cher: p+� <br /> REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL NAITSIS "�) .� U� '71P7 <br /> ail Samples Received es a epth to Ground 'dater of/Tear verage ArnuaL Precipitation = 4 0-25 <br /> -i-Site Well Cs) es a ember & Type Irr am ub <br /> S core S Scare S Care <br /> istance to Well(s) from Tank ft; ft; ft C 0 pts t 9 pts C pts <br /> 0 if O if 0 if <br /> R ondition R ondItion R orditicn <br /> Site Feature - Leaching Potential Analysis E is met E is met E s met <br /> ini;sxntDepth to groundwater from the Sait Saaple (feet)�Q 3 >i00 1-100 25-50\1 <br /> •actures4 n subsurface (applies to foothi[L$ or mountain areas) None Unknown resent <br /> rcrage Annual Precipitation (inches) KXXXXX <10 9 10-25 xxxxxxx 26-40\2 <br /> in-Made conduits which increase vertical migration <br /> Leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> iin;e site features: Recharge area, coarse soil, nearby wells. At least lore than <br /> xxxx None q one ene <br /> COLUMN TOTALS»>TOTAL P014TS <br /> mmpte Resu (B T OR E RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or less <br /> B T x E B JT x E <br /> Vi <br /> b $ �{Q• HAXIHLH ALLOWABLE 8-T•x-E LEVELS 09m) 1 50 50 50 .3 .3 1. 1. 4A\3 <br /> mple Res It: to ASOLINE 1000 100 10 ; <br /> !$ f 1 O00AXIHUN ALLOLIABLE TPN LEVELS (PPN) <br /> 3t aQ � _ 1ESEL i0,0O0 1GOO 100 <br /> OTNOTES: *"If docunented soil and/or ground water contamination is present, do not complete the Leaching potentia[ <br /> analysis. (i.e., site is currently on UCT Contamination List for soil or ground water.) <br /> \1 If depth is > 5 ft. and < 25 ft., scare 0 points, If depth <=5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels .for 8TX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> STAFF RECCMEVDATICN/CCNCLUSION , <br /> Are BTx L E or TP!i Concentrations > Allowable Levels Yes o <br /> Recommend Site Ctosure es o If Yes, Refer to Site ?litigation for Evatuation <br /> REVIEV EVALUATION - TO BE CCHPLETEO BY A SUPE.4VISOR/SENICR <br /> ONCUR WITH STAFF RECCNHE4DATlON FCR CLOSURE IES 0 EFE.2RED TO SITE HITICATICN FOR EVALUaTIGN IES O <br />' nIE REFE3RED / / ATE CLOSURE LETTER MAILED f / <br /> AME CF <br /> VALUATOR <br /> a Z3 ea•(ucruzsHT)\ o <br />