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SANIIIACUI NTY PUBLIC HEALTH Sc'2VICS/EMVIRONMEVTAL N DIVISION <br /> I �ST WORKSHEET FOR SITE CLOSURE EVALUATION CODE <br /> � <br /> NAME OF FACILITY �' '') SWE-DS CODEI / <br /> ADORESSI75 _ � Sf (TANK ID -1 <br /> (TANK SIZE) 1FUEL ilPEI <br /> 11. GENERAL SITE HISTORY <br /> Is permit current?IYesI NoI 1Pa mir 31 - IFaCiI sty Status Coder 11ooc.Sail/GW ContiYes INo <br /> INumer of Tanks at facility Age of Tanks(if available)( 1Type of Tank'Steel lyFhrgtI ISngl Dual) <br /> III. TANK HISTORY LNc 5-fatee cl I I &q 0055 "Alk <br /> was Tank tested?IYes WNo (Failed precision test ?IYes 1 lNoI IIf yes, give date(s)13 li4t ID-3 ID-3GY/12[/03 <br /> Was a repair made to the tank systemT?IYes Mal' IEf yes, what was repairea?i w $ ! [ PcY, <br /> Was repair done under inspection?I Yes 1xal (Were soil sa ctes analyzea?'Yes I INa! JITXEJ (TPH-G' TPN—DI IPb/E08I <br /> Type of failure/discharges IcatastrophicI hang-term Leakage Ioverfilt! 'unkmwnl (other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE OETAILS/COLLECT DATA FOR 1EACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received IYess INos (Depth to Ground Water <br /> 60I Ref/Yea r1 S' (Average AnnuaL Precipitation A=114. 110-25 <br /> On-Site WeLL(s)IYes INos 1NUmber L Types IIrrl 10am1 (Pubs <br /> S Scare S Scare S Score <br /> Distance to Wells) from Tank) ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if O if <br /> R condition R condition R condition <br /> V. Site Feature - Leaching Potential Analysis = is met _ is met E is met <br /> Minimmam Depth to groundwater from the Soil Sample (fe-_t)sD-_ s I >100 s 151-100 I .5 s. 5-50\1 <br /> i <br /> 1Fractures in subsurface (applies to foothills or mountain areas) ) A I None I I Unkmm I Present <br /> 111 � <br /> (Average Annual Precipitation (inches) 1==xl <70 1 9 1 10-25 lm=xxxl 25-40\2 <br /> (Man-Made conduits which incresse vertical migration 1 <br /> Iof leachate (i.e., septic systems, water wells, ponds) None I Unknown 'Present <br /> Unique site features: Recharge arca, coarse sof L, nearmy veils. I At xxpLeast More than <br /> = .Vane one one <br /> S» <br /> COLUMN TOTALTOTAL POINTS I ' U I - = / <br /> Sample ResU1Lt�: (3 T X E) RANGE OF TOTAL POINT pts ar more 41 - 4a pts I 40 pts or Less <br /> R T X 3 i X E <br /> 1 1 1 1 MAXIMUM ALLOWABLE 3-T-X-E LEVELS CPPM 1 50 50` 50 3 I.3 1. 1. NA\3 <br /> sample Result: GASOLIN 1000 ! 100 10 <br /> 0-9, 3 �`�'e (MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> 1 0 114 TPH 0(Esc^_ 10,000 1 1000 100 <br /> FOOTNOTES: If doaaented soil and/or ground water contaminatf &aching patentiai <br /> analysis. (i.e., site is currently an UGT Ca ttamination List for sail or ground water.) <br /> \1 If depth is > 5 ft. and < 25 ft., scare 0 points. If depth c5 f ., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for STXSE are not appiicable at a MH concentration of 10 ppm (gasoline) or 100 ppo (diesel). <br /> VI. STAFF RECCMMENDATION/CONCLUSION -T,4r) 1.6 A 4-3 h a4'-O-- <br /> 1. Are 3TX i _ or TPH Concentrations > ALLowable Levels I'Yes Nos ( �yujl7 ZW&P.".,f�■yT4-t,149Y 74* <br /> 2. Recanmend Site CtosurelYes) INo If Tes, Refer co Site Mitigation for EvaLuatian -r,�lE - /TL{�.it.Q""yV- Obr• <br /> VII. REVIEW EVALUATION - TO 3E CCMPL--M 3T A SUPERVISOR/SEMIOR f tet/ I" !AJ>- a�Qa <br /> ' <br /> CCNCUR WITH STAFF RECAtlMENDATIOM FOR CLOSURE YES INDI RE:E3RE3 TO SITE MITTGATIOM FOR EVALUATIONITESI IMCI I <br /> DATE REFERREDI / / (DATE CLOSURE LETTER MAILED! <br /> NAME OF <br /> EVALUATORI <br /> EH 23 80 (UGTWKSHT)\5/90 . <br /> • <br />