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/ SAN .CACUIH C3JNTYX HEALTH SFRVICES/E4VtRC4NEHTAL HEALTH O�CN <br /> UGST SHEET FCR SITE CLMAE EVALUATION � AlE I S z,& q1 <br /> arE OF FACILITY. I Vi I Q e 'ncA .EEPS CCCE I D I[ <br /> TANK ;0 1 - O <br /> MANX SIZE 1101 DCO EL TYPE <br /> GENERAL SITE HISTCRY <br /> Iz permit cnrrenelea o ermit 3 I acflfty Status Code V oc.5 Cmc es o <br /> aumoer of Tanks at facility 3 ge of Tanks((f available) q r ype of Tank :eelhrglngl Dual <br /> L IANX HISTORY <br /> tAs Tank ;ested7 es o ailed precfsim test es a 11 f yes, give date(s) <br /> ras a repair made to the tank system? es No f yes, what was repaired? <br />:as repair done under inspection? es ere soft samples analyzed? es o TXE RH•G PH-0 b/E08 <br /> Ype of failure/discharge at trophic long-term leakage verf ill mown ther: <br /> REMOVAL HISTORY (ATTACH INSP CTICN REPORT FOR SITE OETAILS/CCLLECt OATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Receivedes o epth to Ground Vater 'p - of/Year ; $6 verage Arnual.Precipitation 4 0-25 <br /> n-Site Well(s) es o +ober d Type It rr um ub <br /> Score S core S core <br /> I stance to Vel I(s) Irom Tank ft; fr, ft C 0 Pts C pts C pts <br /> 0 if 0 if 0 f <br /> R ondition R mdition R ondition <br /> Site Feature - Leaching Potential Analysis "c is met E is met E s met <br /> inimtm Oepth to groundwater from the Soil Sample (feet)/�_ >t0; >100 I 1-100 I 25-50%1 <br /> ractures in subsurface (applies to foothills or mountain areas) lime Unknown iresent <br /> verage Arcual Precipitation (inches) xxxz 00 9 10-25 xxxxxx 26-40\2 <br /> in-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br />+ique site features: Recharge area, coarse soil, nearby wells. I At least ore than <br /> �omxxx None one one <br /> CCL" TOTALS>»TOTAL POINTS <br />:mole Result. (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or less <br /> B T X E B T % E <br /> MAXI". ALLCUABLE B-T•X-E LEVELS (PPM) 1 50 50 . 50 .3 .3 1. 1. NA\3 <br /> Nople Result: SCLIHE 1000 100 to <br /> 1FtJN ALLCwABIE TPH LEVELS (PRN) <br /> TPH IESEL 10,000 1000 100 <br /> CtHOTES: ***If documented soft and/or ground water cmtamination is present, do not complete the leaching potential <br /> analysis. (I.e., site is currently on LOT Contamination list for soil or ground water.) <br /> \1 If depth is > 5 ft. and s 25 ft., score 0 points. If depth �5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 levels for 3TXdE are roe applicable at a TPH conte tratimn of 10 ppm (gasoline) or 100 ppm (diesel). <br /> STAFF RECCMMENOAT ICH/CCNCLVSICU <br />. Are 3TX 4. E or TPH Concentrations > Al wable Levels Yes o POP) <br />. Recommend Site Closure es 0 If Yes, Refer to Site Mitigation for Evaluation 1=&^Dptri <br /> REVIEW EVALUATION . TO SE COMPLETED BY A SL9ERVISCR/SENICR i Pyr' i?oG,,�/n <br /> CHCUR WITH STAFF RECCMMEHOATtON FOR CLOSURE �SS I EF"cRRED TO SITE MITIGATION FOR EVALUATICH AYES O <br /> ATE REFERRED ATE CLOSURE IE TTER MA ILEO ` f I <br /> nME OF <br /> 1 <br />/ALUAIOR Yf <br /> t 23 SO (UGP.ZSHT)\5/90 Ij <br /> I <br />