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SAN 1GCUI9 C.S,0 '_IC HEALTH SERVICES/ERVIRCHMENTAL HEALTH ICH - <br /> UGST _-wKSHEET FOR SITE CLOSURE EVALUATION - ATE I 9 4 C? <br /> EEPS CCOE 6� <br /> +n0aE5S I <br /> A505- <br /> 5 u. �rCAUK to Y/✓✓��j IT - <br /> J/ PLT O <br /> rANK SIZEJI/L�To 0 UEL'TYPE <br /> GeME.RAL SITE HISTORY 1� <br /> rs ,Permit current? es o ermi[ 4 T.J aeility Status Code 8 o x.Sai(/GV Conc as <br /> 0 <br /> 4unber of Tanks at facility ge of Tanks(if available) Z ). ype of lank Leel Crgl rgl Dual <br /> TANK HISTCRY 4e.,4- -12 66 <br /> .'as Tank eested7 I es o ailed gree ision test es a If yes, give dates) <br /> -'as a repair ,made to the tank system? as 40 It yes, what was repaired? <br /> -.s repair done render inspection? les ere soil sa ples analyzed? es o TXE PH-G IYaH•0 pb c <br /> /_DB <br /> -'oe of failure/discharge alas cr ph ie long-term leakage I verti It known cher: <br /> REMOVAL HISTORY (ATTACH 14SPE ION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALTSI S) <br /> :oil Samples Received ) es 0 epth to Ground Vater )Cl/ of/Tear verage Arnual Precipitation = 4 0.25 <br /> -.Site Vett(s) I es o umber 3 Type Irr I Post ub <br /> stance to Vell(s) from Tank "P'ft; f S core S core S core <br /> ,. t; ft C 0 pts C pts C pts - <br /> - O if 0 if 0 •f <br /> Site Feature - Leaching Potential Arra lysis R ondition R ondition R ordition <br /> E is met E is met E 's met <br /> ;iaxm Depth to groundwater from the Soil Sample (feet) _�Dc �� >I00 I 1-100 I /" <br /> 25.50\1 <br /> ;ctures in subsurface Capplies to foothills or motntain areas) None <br /> Unknown I resent <br /> ,rage Amual Precipitation (inches) xxxx s10 I 9 <br /> 10-25 zzzxxx 26-40\2 <br /> --Made carduits Which increase vertical migration <br /> leachate (i.e., septic systems, water wells, ponds) None <br /> Unknawn resent <br /> •e site features: Recharge area, coarse soil, nearby wells. AC least ) are than <br /> __ xzxx None one ane <br /> CCLLM TOTALS>>>TGTAL POINTS <br /> ale Result: IS T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 PCs I 40 pts or less <br /> =2'6ppa\ E�ZVppa. <br /> MAXIALH %LLCWA8LS B-T-X-E LEVELS (PPM) 4 50 150 150 .3 .3 1. 1. 1 4A\3 <br /> -:ie Resul C: ASOCINE 1000 100 10 <br /> 3C UM AX IF471 ALLCUABCE TPH TPH LEVELS (PPM) lESEL 10,000 1000 100 <br /> ::+OTES: •••If documented soil and/ac ground water contamination is present, do not complete the leaching potential <br /> analysis. (I.e., site is currently on UGT Contamiration list for soil or ground water.) <br /> \1 If depth is > 5 ft. and s 25 ft., score 0 points. If depth t=5 ft., do not use table. <br /> \2 If precipitation is > GO inches, score 0 points. <br /> \3 Levels for STXEE are roc applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> :TAFF RECCFHE40AT(ON/CCNCLUSION <br /> Are BTX 3, E or TPH Concentrations > All wable Levels Yes o <br /> Recommend Site Closure as I o If Yes, Refer to Site Mitigation for Evaluation <br /> 'EV!-EW EVALUATION - TO SE 'CMPLETED BY A SUPERVISOR/SEMICR <br /> GS'R WITH STAFF RECCHMENOATION FOR CLOSURE �4E5 0 I EF-ERRED TO S1TE 4fTICATICN FOR EVALUATION II•ESI 0 <br /> ' tEFERRED / / PATE CLOSURE LETTER MAILED ' ¢ / <br /> r CF <br /> :ATOR <br /> e0 (UGIVXSHT)\5/90 <br />