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SAN 10ACUIH CCUHTY .IC HEALTH SERVICES/E.HVIRCHMENTAL HEALTH 0 'CN / <br /> UOSV-_kXSHEET FOR SITE CLOSURE EVALUATION AIE <br /> +nr.E OF FACILITY I ermay� + t ( Mpg„ EEPS cone <br /> AXX Lo x Q� <br /> ILiHX SIZE 3 1 Q00 UEL TYPE E' <br /> el'l1 <br /> i. GENERAL SITE HISTORY <br /> Is permit currene7 des o ermit ;9 - N aeility Stan Code �i O ae.Sail/Gu Canc �Y es <br /> a <br /> 11 uatoer of Tanks at facility ge of Tanks(If available) Z !S ype of Tank Leel brgL rgl Oual <br /> 1. TANK HISTORY (ate- 1,786 <br /> Is Tank tested? as a ailed precisim test es o If yes, give date(s) <br /> ;as a repair made to the tank system? as <br /> 00 f yes, what was repaired7 <br /> ns repair done larder inspection? I es W Jere soil samples analyzed? es o TXE PH•G I PH-0 b/E08I <br /> �YPe of failure/discharge atastroph is long-term Leakage verfill 'noun cher: <br /> REMOVAL HISTORY (ATTACH INSPE ICN REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) LLL <br /> ,it Samples Received as a epth co Gratrd Yater Ur. of/Tear ;8b verage Annual Precipitation = hG 0-25 <br /> -Site Yells) es o unber d Type Irr on ub <br /> +stance to Yells) from TankLGYI� ft; ft; S care S core S care <br /> ft C 0 pts C pts C pts <br /> 0 f O it 0 <br /> endit <br /> Site Feature Leaching Potential AnaR ondition R enditfon R ion <br /> lysis _ E is met E is met E 's met <br /> ininm Dep ch to grcurdwacer from the Soil Sanpte (feet)2—(0�.�Z T >100 I 1-100 I<2`f 25-50\1 <br /> 'actures in subsurface (applies to foothills or mountain areas) Hone I Unknown / resent <br /> crage Amual Precipitation (inches) x x I <10 9 110-25 xxxxxx 26-40\2 <br /> '-.7-Made cordui is which increase vertical migration <br /> ieschate (i.e., septic systems, water wells, ponds) None I I Unknown I resent <br /> '; a site features: Recharge area, coarse sell, nearby wells. I At least ) are than <br /> xxxx None one I one <br /> COLUMN TOTALS»>TOTAL POINTS r I l <br /> 'ale Result: (3 T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or fess <br /> DppAw <br /> Z IoM g3�;DM MAXIML.N ALLCVASLE 3-T-X-E LEVELS (PPM) 1 150 I50 I50 .3 .3 1. 1. I NA\3 <br /> -:ode Result: �AXIMUM <br /> ASOLIHE 1000 100 10 <br /> ALLOVABCE TPN CEYELS (PPM)TPH fESEL 10,000 1000 100 <br /> f40TES: • If documented sail and/or ground water contamination is present, do not complete the leaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for sail or graund water.) <br /> \1 If depth is > 5 ft. and a 25 ft., score 0 points. If depth 4=5 ft., do not use cable. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for 3TXSE are roc applicable at a TPH concentration of 10 ppn (gasoline) or 100 ppm (diesel). <br /> 'AFF RECCMENDATIOH/CCNCLUSION L�Qd /V M <br /> Are 8TX L. E or TPM Concentrations > ALL able Levels Yes o <br /> ReaOMMend Site Closure as �!o If Yes, Refer to Site Mitigation for Evaluation <br /> '/:EY EVALUATICH - TO 3E CCMPLETED 8Y A SUPERYISCR/ScNICR <br /> 7R WITH STAFF RECCMMENOATtCH FOR CLOSURE ESI 0 EFERREO TO SITE MITIGATION FOR EVALUATICH 4ES I �0 <br /> REFERRED / / ATE CLOSURE LETTER MAILED f / <br /> CF <br /> ATOR <br /> -> 80 (UGTVXSHT)\5/90 <br />