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- 3/ <br /> SAN JOMINC PUBLIC WEALTH SERVICES/ENVIMMMENTAL HEA"IVISION <br /> t' T WORKSHEET FOR SITE CLOSLRE EVALUATION <br /> DATE <br /> HANE OF FACILITY L LAI C, j , , <br /> � S{IEEPS CODE <br /> ADDRESS <br /> l 04w TANK i0 0 . <br /> TANK SIZE FUEL TYPE � ^ Z <br /> II. GENERAL SITE HISTORY <br /> 01 <br /> Q/ <br /> Is ptrait current? Yes No Permnit t - Facility Status Code Doh:.Soit/GW Cant Yes No <br /> Number of Tanks at fecitity Age of Tanks(if evailabts) Type of Tank Steet Fbrgl Shpt peal <br /> Ili. TANK HISTORY <br /> Vas Tart tested? Yes Mo Failed preaisian test ? Yes f yea. give wate(s) ;. p / . , <br /> Was a repair mode to the tank systart Yea 10 If yes, what has repaired? ` <br /> Was repofr Bono under inspa:tion? Yes soil sasplea analyzedt Yos No BTXE TPN-G TPN-D Pb/EDB <br /> Type of fafturWdischarge catastrophic. , t t�mmm:leakage overfILt tahknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION MM- SITE:DETAIl3/COLLECT DATA FOR LEACH11M POTENTIALANALMS) <br /> Solt Samptss Raceived Yes No Depth.to Ovir d Water Ref/Year ; Average Annual Precipitation A• 14 10-25 <br /> On-Site Wetl(s) Yes NoNumber S Type lorl Dpa Pub <br /> S Score S Score S Score <br /> Distance to Watt(i) fromTank ft; _ftp ft CC 10 if pts C lfpts 0 tpts <br /> R condition R tttoii R condition <br /> V. Site Feature • Leaching Potential Arhelyais E is met E is alit' E is Mt <br /> Ninimur Depth to groundwater fromi the Soft Ssaple tfeet) >100 51-100 25-50\1 <br /> Fractures in subsurface ( -. <br /> appliea to foothills or mountain cress) None pmt <br /> Average Arwont Precipitation (inches)` xxxxxx <10 9 10-25 x70uxxx7u -40\2 <br /> Men-Made Conduits which incrqoe vertfast, aipradon <br /> of leachate (i.e., septic syst4*,L water watts, per) None Vnkndwn Present <br /> Unique site features <br /> e Recharge area, coarse soil, nearby netts. At least Nora than <br /> xxxxxx NOW one ane <br /> COLUMN TOTALS»>TOTAL POINTS + + s <br /> Sample Resutt: (B T X OR E) RANO[ OF TOTAL POINTS 49 pts or Dore 41 48 pts 40 pts or less <br /> 81 T X. E B T X E <br /> MAXIMUM ALLOW SLE 6-T-X-E LEVELS (PPM) 1 SO SO SO .3 .3 1. 1. MX3 <br /> Sampto Result: AL - GASOLINE 1000 100 10 <br /> MAXIMUALLOWABLE TPIN'LEVELS (PPM) <br /> TPN DIESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil MWOr ground hater contmellnetian:fs present, do not-cosptate the tesdnfne-potentfat <br /> anelysfs. (t.e., site is currently on UBT Contashfnetfon List for soil or ground water.) <br /> \1 If depth Is >, S ft. sed s 25 ft., score 0 points. If depth cats ft., do not use table. <br /> \2 If precipitation 'Is > 40 rods", score 0 point's. <br /> \3 Levels for BUM ere Mt. applicable at a TPH eoncentratfon of 10 ppot (gasoline) or 100 ppo Wisest). <br /> VI. STAFF MCOIMiUMATION/CONCLUSION <br /> I. Are BTX i E or IN Coneehtratfa t > Attousbte Levels *Yes No <br /> 2. Reaamwmnd Site Closure Yes Mo If Yes, Refer to Site Nitfestion for Evatuation <br /> VII. REVIEW EVALUATION - TO BE OONPLETED BY A SUPERVISWSENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CU.=xtE YES NO REFERRED TO SITE <br /> MITIGATION FOR EVALUATION YES 1901 1 <br /> OATS REFERRiti) / /" - DATE CLOSURE LETTER MAIL$D / <br /> NAME Of <br /> EVALUATOR <br /> EH 23 80 (UGTMWT)\5/90 <br />