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r <br /> SAN ,lOAOUi PUBLIC HEALTH SERVICES/ENVIRONMENTAL F �ti�ViSION <br /> t. UST WOPKSSHE'ET// FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY '�r �! UiT G�f^S CORD ID <br /> DORESS O A 3 <br /> N}K�Io <br /> ANK SIZE L TYPE ! !�/ {� V'Y / /Af <br /> II. GENERAL SITE HISTORY f`-' <br /> Is permit current? es o ermit 9 - acitity Status Code oc.SOiL/C;w Cont es o <br /> Ember of Tanks at facitityge of Tank(if available) ype of Tank teel brgl. ngt I Dua[ <br /> III. TANK HISTORY <br /> as Tank tested7 as o ailed precision test ? . as a If yes, give date(s) <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> as repair done under inspection? es 401 ere soil samples analyzed? es I o I TXE I PH-G I PH-D b/IDB <br /> ype of failure/discharge atastraphic long-term leakage verfill. ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR i.EACHING POTENTIAL ANALYSIS) <br /> 6L samples Received es INCI epth to Ground .Yater ef/Year verage Annual Precipitation <br /> On-Size ueLL(s) es o umber Type Irr csm u6 <br /> Score S Score S care <br /> istance to ue M s) from Tank ft; ft; ft C I 0 pts C 9 pts C pis <br /> O if 0 if 0 f <br /> R zondition Rondition R ondition <br /> Site Feature - Leaching Potential Analysis E s met E is met E s met <br /> linimum Depth to groundwater from the Soit Sample (feet) >100 1-10 25-50 1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown 5resent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 Kxxxxxx 25-40 2 <br /> an-trade conduits which increase verticat migration <br /> f Leachate (i.e., septic systems, water wells, ponds) None Unknown 3resent <br /> niaue site features: Recharge area, coarse Bait, or wells. At Least 4ore_than <br /> �} [Mi+uncioal=>2O00 ft; domestic-500 ft; irr/agricuLturat=presentl xxxxxx Mane one one <br /> COLUMN TOTALS—TOTAL POINTS + + <br /> ample esu t: (B T X OR E) RANGE OF TOTAL POINTS 9 pts dr more 41 - 48 pts 40 pts or less <br /> St �,A 030 B 7 x 1150®. � A -T-X-E LEVELS 1 50 50 3B Xi1. NALO 1 <br /> ampte Result: Tt'N `3 SOLINE 1000 100 10 <br /> S a A a,go0TP !� IMUM ALLOWABLE TPN LEVELS (PPM) IESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the Leaching potentia[ <br /> analysis. (i.e.. site is currently on UGT Contamination list for soil or ground water.) <br /> L If depth is > 5 ft. and < 25 ft., score 0 points. If depth c=5 ft., do not use table. <br /> L If precipitation is > 40 inches, score 0 points. <br /> )3 Levets for M&E are not applicable at a TPH concentration of 10 ppm (gasoline) or.IGO ppm Cdiesel). <br /> VI. STAFF RECOMMENOATION/CONCLUSION �a/1�L �fio G_r�i <br /> 1. Are BTX i< E or FAH Concentrations > Allowable Levels Yes o I1,j CL41 t2E61 �XC �' <br /> 2. Recommend Site Closurees oJ�jfes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED SY A SUPERVISOR/LEAD SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES F�31 FERRIED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / J ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> cH Z3 30 (UGTIIKSHT)\5/94 I <br /> P <br /> L <br />