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SAN uaAGO"i. =LINTY PUBLIC HEALTH 3ERVICES/ENVIRONMERTAL1-6LTH1 DIVISION _ <br /> i UGST w0RKSHE=T FOR SITE CLOSURE EVALUATION 1OATEti <br /> ' I ' � 3 I� 1S <br /> .NAME Of =AGILITY I 04%i >� �/jE/O S�PSMOE <br /> ,ADDRESS /! j'� S }TANK ED »)3 I a <br /> 'TANK S M IJ-0 c� �E'- TYPE( /�' %YLL Lv14t�� G% �f -�-�- + �' V. / Yi <br /> i <br /> ii. GENERAL SITE :HISTORY <br /> :_s permit current? Yes INo! }Peron :� (facility Status Code IDoc_Soil/GJ Cant �lll <br /> oHunber of Tanks at facility 'Age of Tankso4 availabie)i (Type of Tank�Steell IFbrgtl ISngll O <br /> ill. TANK HISTORY <br /> :Was Tank tested?iYes l INo{ failed precision test ?;Yes INC It yes, give dare(s)I <br /> ;'Jas a repair ;nade to the tank system?I Yes i Vo' 'if yes, what was repaired? <br /> ;:Vas repair done under inspection? Yes INo} were snit samples analyzed?j.Yesi �Noi IBTXE� iTPN-GI (TPH-Di !Pb/S3. 81 <br /> Type of failure/discharge (catastrophic; }Long-term Leakage Ioverfiltl }unknown} (other- <br /> iV. RE140VAL HISTORY (ATTACH INSPECTION .REPORT FOR SITE DETAILS/CCLL_CT DATA POR LEACHING POTENTIAL ANALYSIS) <br /> ;Soil Samoles ReceivedlYesi }Ila (Depth to Ground aaterl }Ref/Year; }Average Annual PrecioitationlA=�14 Ila-25] <br /> iOn-Site Vetl(s)IYes f INo( (Number 3 Type{ IIrrI ? IIPuol <br /> S Score S Scare S Scare <br /> i0istance o uell(s) `ran Tankl rt; ft; ft C 1Q pts C 9 pts C 5 pts <br /> If D ST Q if <br /> A }condition R csndition� A �eondition <br /> v, Site Feature - Leaching Potential Analysis ins ,pot _ its :net - is wet <br /> Minimum Oepth .o groundwater tram the Soil Sample (feet) >t0O i �5i-SOQ I Z5-:Q\i <br /> rac:ures in subsurface (acplies to foothills or ,nountain areas) f { None i I Unknown !Present <br /> :average Annual Precipitation (inches) xxxxxxI <10 I 9 M-15 ;xx:vooal 26-44\2 <br /> Man-'Race conduits which increase vertical migration pp�� <br /> of leachate <i.:., septic systems, water wells, ,ponds) j (1 ' None � � Unknown � �Prtsert <br /> Mare than <br /> ;Unique site features: Recnarge area, coarse soil, nearny •sells. /3 I At least I <br /> xxxxxxi :gone �17 i one one <br /> / 01 <br /> r COL T LS>> OTAL POINTS U I I L <br /> i <br /> Samole Result: (3 T X OR E) RANGE OF TOTAL POINTS 49 pts or more I 4.1 - <•d pts I pts or less <br /> IP�S x P06 X18 <br /> ' IJB� 3 V MAXIMUM ALLOWABLE d-T-X-c I,r-YELS (PPM) 3� SO� 50� 50 i 3 1.7 <br /> 3 + t.f 1. NA\3 <br /> ! + <br /> Sample Result: (GASOLINE ma I 100 ! 10 <br /> MAXIMUM ALLOWABLE TPN LEVELS (PPM) <br /> TPH !DIESEL 10,000 ! 1000 i 100 <br /> !FOOTNOTES: * T f documented soil and/or ground water contamination is present, do not ca=lete the leeching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground eater.) <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. if depth =5 ft-, do not use table. <br /> \Z If precipitation is > 44 inches, score 0 points_ <br /> \3 Levels for 3TXSE are not applicable at a TPR concentration of 10 ppm (gasoline) or 100 ppm (diesset). yk <br /> �y <br /> VI. STAFF RMM <br /> ECCEMDATION/CONCLUSION il 3 HER dPP mi IZ)y�j <br /> 1. Are 3TX 3+ ° or TPH Concentrations > plowable Levels I'Tesi INo i(F;f / P_P <br /> i �_ %,3 <br /> 1 2. Recommend Site ClosureYesi INo( If Yes, Refer co Site mitigation for Evatuationi <br /> VII. REVIEW EVALUATION - TO 3E aMPLETED 3Y A SUPERVISOR/SENIOR P <br /> iCONCUR WITH STAFF RECCMEMDATION FOR CLOSURE YES( IN01 IRE.'-ERRED 70 SITE MITIGATION FOR EVALUATIOMiYESt JUDI 1 <br /> DATE REFERREDI / / (DATE CLOSURE Lczru MAIL`DI <br /> NAME OF <br /> EVALUATOR <br /> "eH 23 30 (UGTWSHT)\5/90 <br />