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SAV �OACIfIK TY,PUBLIC HEALTH SERVICESlE4VIRCHMENTAL HEA u_DEYISIOH DATES <br /> w=SHEET FCR SITE CLOSURE EVALUATION '4 5 3 a 3 <br /> lnvcs SVEEPS CODE <br /> NAME OF FACILITY LZ <br /> I <br /> ADDRESS H%- N. rAPC o� 7 o n C � C TANK ID - DS 1 rjjp5 <br /> TANK SIZE I'poo FUEL TYPE �y� pWyl <br /> I. GENERAL SITE HISTORY _** <br /> Is permit current? Yes No Permit # <br /> Facility Status Code Doc.Soil/GW Cont YeMU'L Nurber pf Tanks at facility Ulk� yVh1 Age of Tanks(if availabte) W&V4VW Tyle of Tank Steel Fbrgl Sngl <br /> :It. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test T Yes No If yes, give date(s) <br /> lWas a repair made to the tank system? Yea No x If yrs, what was repaired? <br /> Stas repair done under inspectian7 Yes Na Vere soil samples analyzed? Yesl")( Ho BTXE [TPH-GI TPH-D - Pb/ED8 <br /> Type of failure/discharge catastrophic Long-Lerma leakage overfill ts�knora� other: <br /> iV. REMOVAL HISTORY (AITACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Ground Vater f/Year 1'9 ;J� Average Arcual Precipitation A-114 10-25 <br /> On-Site Well(:} Yes N V Nu�er L Type Irr Dam Pub J <br /> /` 5 Scare S Score S Score <br /> ft. ft C 10 pts C 9 pts C 5 pts <br /> Distance to Wetl(s) from Tank ft; 0 if O if 0 if <br /> R condition R condition R conditicn <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> IMinimum Depth to groundwater from the Soil Sample (feet) #( _�. <br /> 51-100 �j 25-50 1 <br /> Fractures in subsurface (applies to foothills or caxrstain areas) Present <br /> Average Annual Precipitation (incises) 10-25 xxxxxxx 26-4012 <br /> Han-Made conduits which increase vertical migration None a Unknr� Present <br /> of leachate (i.e., septic systems, water wells, ponds) ` <br /> Unique site features: Recharge area, coarse soil, nearby wells. q At least More than <br /> xx7cxzz None 1 one one <br /> COLUMN TOTALS»>TOTAL POINTS ; 1312 ; J 1- 41 <br /> Saapte Result: (a T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> B T X E B T X E <br /> x":-7•3 MAXIMUM ALLOUABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sarspte Result:z qoo ALLC <br /> D: GASOLINE 1000 100 10 <br /> ?tAXIte:74 VASLE TPH LEVELS (PPM) <br /> Cj l��Gyl y DIESEL 10,000 1000 100 <br /> FOOTNOTES: **'*If documented salt and/or ground water contamination is present, do not complete the teaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for sail, or grot;d water.) <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth "S ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> 1.3 Levels for BTXEE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOWENDATICN/CONCLUSION <br /> 1. Are BTX b E or TPH Comentrations > Attowable Levels 'Yes Na X <br /> 2. Recocipel Site Closure IYes Np x If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATICN - TO BE COMPLETED BY A suPERVISCR/SENIOR <br /> CCNCJR WITH STAFF RECCMENDATICN FCR CLOSURE YES NC REFERRED TO SITE MITIGATION FOR EVALUATION YE NQ <br /> GATE REFERRED _`.� / .� / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR I <br /> - 1 <br /> EH 23 80 (UGTVKSHT)\5/90 <br />