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SAN JCACUIN iTY PUBLIC HEALTH SERVIC4-S/ENVIRONMENTAL HE ' OIVISICN <br /> I SST 'WORKSHEET FOR SITE CLOSURE -EVALUATION €DATE (Q <br /> � 4 <br /> NAME OF FACILITY SWEEPS CODE i i � �; ' <br /> `TANK tD �Cf / .�� <br /> iaooaEssl 3,, 3 /� G��S .sir / <br /> TANK S I Z£ <br /> iI. GENERAL SITE HISTORY <br /> t <br /> I[s hermit current?iYes Nxol lPermit :� Facility Status Coder IDoc.Sail/GW Cont#Yes Nol <br /> lNumoer of ranks at facilityl lA9e of Tanks(if aa <br /> itable)i (Type of rankjSteetl IFbrgtl ISngtl oua/ll <br /> I I I. T ANK HISTORY 6, U/.G`t5 hCG" G� Lt/ �. -F, /' C <br /> (Was rank tested?IYes I INoI IFaiLed precision test ?IYesI><IgoI lif yes, give date(s)l /V <br /> Was a repair made :o :he tank systen?IYeslNol lif yes, what was repairedll <br /> Was repair done under inspectionTesl lNoi 1Were sail samoles analyzea?IYesl INC STXEI ITPH-Gf ITPH-DI IPb/EDE <br /> Type of failure/dischargel lcatastrophicl (tong-term Leakage] loverfiltl lunknownl lotner: <br /> IV. REMOVAL 41STORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FAR LEACHING POTENTIAL ANALYSIS) <br /> (Soil Samples ReceivedlYesl INol (Depth :o Ground Waterl (Ref/Year) IAverage AnexsaL Preeipitationk=jl4- 110-25 <br /> i1 <br /> Ion-Site Wetl(s)IYes) INoI (Number Y. Type l IIrrI Dom! IPupl <br /> S Scare S Score S Score <br /> Distance to Wetl(s) from Tankl ft; ft; ft C �10 pts C 9 zts C 5 pts <br /> 0 if 0 if 0 if <br /> R condition R condition R condition <br /> IV. Site Feature • Leaching Potential Anatysis c lis :net _ is met c is met <br /> (Minimum Depth to groundwater from :.tie SoiL Sample (feet) `T'd ,� >i00 1 151-1Q0 l - i 25-50\1 <br /> rl �� <br /> IFrsctures in sucsurface (appties to foothills or mountain areas) 1 f; None i I Unknown I !present <br /> IAverage Annual Precipitation (inches) 1%ocxxxxl <10 I 9 l 10-25 l=xxxxx! 25-4Q\2 <br /> I <br /> Man-Made conduits which increase verticat migration n <br /> hof Leachate (i.e., septic systems, water wetLs, ponds) (I(� None I Unknown I (Present <br /> Unique site features: Recharge area, coarse soil, neartzy wet Ls. I At least (Mare than <br /> xx <br /> �xxxx � None � rn+ <br /> � e� I oneIr <br /> } <br /> I 11 <br /> COLUMN iOTAt>»TOTAL POINTS <br /> Samole .Result: (4 r X OR E) RANGE OF TOTAL POINTS 49 pts or more l +� - 40 pts or Less i <br /> + K3 k,1 x b05S/ 7K9­1 3!' rE 3 XI MAkTMUM ALLOWAABLE 3-T-X- LEVELS (PPM) 1! 50� 50� S0 .3 1.3 ( 1r X. <br /> 1. ( NA\3 <br /> Sample Resuit: I GASOLINE 1000 i 100 I 10 <br /> TPN MAXIMlD1 ALLOWABLE TPN LEVELS (PPM)10EESEL 10,000 1000 100 <br /> FOOTNOTES: ' Tf dormented soil and/or ground water contamination is ptete resent, do no the Leaching potentiaL <br /> analysis. (i.e., site is currentty an UGT Contamination List for snit or ground water.) <br /> \1 If death is > 5 ft. and < 25 ft., score 0 points. if depth `5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, sere 0 points. <br /> \3 Levels for 3TXSE are not applicable at a TPS! concentration of 10 ppm (gasoline) or 100 ppm (dieset). <br /> V1. STAFF RECOMMENDATION/CONCLUSION %K 3 N 'f' T� <br /> 1. Are 3TX b E or TPN Concentrations > Atlawable Levels I""es� IHa' (�V, �/av� i A-; <br /> 2. Recommend Site CtosureiYesl lNol ! if Yes, Refer to Site Mitigation for _valuation /�� 1 --" <br /> VII. REVIEW EVALUATION - TO 3E COMPL-=TM 3T A SUMVISOR/SE.IOR <br /> CCMCUR WITH STAFF REr_OMME4DATION FOR CLOSUREIYESi INoi �RE..FaRim To SITE 4ITIGATICH FOR cVALUATICHIYESI INQ) <br /> DATE REFERRED I / / I DATE CLOSURE L-E-i TERR XAILcn i <br /> NAME OF <br /> EVALUATOR' <br /> HH 23 30 (UGTWKSHT)\5/50 <br />