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SAN MAXIM CO PUBLIC HEALTH SERVICES/ENVIRCHMEHTAL HE.tLrIVIvCN <br /> VCRXSHEET FOR SITE CLOSURE EVALUATION _ ATE <br /> NAME OF FACILITY I (S EEPS CODE <br /> 7-" 3� <br /> MOR<_ss l 1/ F/hr S�E� ANz 101 <br /> i"N% SIZE FUEL TYPE <br /> GENERAL SITE HISTORY .. 1(X113 h <br /> is permit current? as a ermit 3 acilicy Status Code �/ -.Sail/GW Cont as o <br /> wue. r of Tanks at facility U �ge of Tanks(if available) I ype of Tank teal brgl ngl Oual <br /> I. TANX HISTORY <br /> Jms rank tested7 es o ailed precision test 7 as o If yes, <br /> -as a repair made to the tank system? es Na f yes, what was repaired? <br /> :as repair dme under inspection? I es �0 �ere sail samples analy;edt If <br /> as a TXE PH-G I PH•O b/EDB <br /> 'ype of failure/discharge atastrophielmg•tenn leakage verffll noun [her: <br /> . REMOVAL HISTORY (ATTACH INSPECTICH ,REPORT FOR SITE DETAILS/COLLECT DATA FOR LEAC:i1HG POTENTIAL ANALYSIS) <br /> ;oil Samples Received I as o epth to Ground Vater S of/Tear /YR.L verage Annual Precipitation = IRC 0-25 <br /> Dn-Site Vett(s) Ices I a Lxber d Type I Ire I am b <br /> 5 core S core S core <br /> )istance to WeIL(s) from Tank ft; ft; ft C 0 pts C pts C pts <br /> 0 f 0if 0 f <br /> R or'dition R - ondition R ondition <br /> �. Site Feature - Leaching Potential Analysis E 's met E is met E 's met <br /> linin Depth to grourdwacer from the Sail Sample (feet) �� �, i I >100 I 1-100 I 25-50\1 <br /> "ractures in subsurface (applies to foothills or mountain areas) INme I Unknown resent <br /> tvcrage Annual Precipitation (inches) xxxx <10 I 9. 110.25 xxxzxx 26-40\2 <br /> `an-Made conduits which increase vertical migration <br /> :f leachate (i.e., septic cyst ams, water wells, ponds) None ( Unknown I resent <br /> nigje Site features: Recharge area, coarse soil, nearby wells. I I -7At least ) are than <br /> xsxx Nine ! we one <br /> CCLL40( TOTALS>>>TOTAL POINTS <br /> ,ample Result: (B T X OR E) RANCE OF TOTAL POINTS 9 pts or more 41 - 48 pts I 40 pts or less <br /> Lk —JLIiE. 0 <br /> -7^ / B T X E B T % E <br /> MAXI". ALLOWABLE B-T•X-E LEVELS (PPM) 1 50150 50 .3 .3 1. 1. 1IA\3 <br /> ;a le Res tt: ASCLINE 1000 100 10 <br /> �-IPUM ALLCUABLE TPX LEVELS (DPN) <br /> FBF <br /> ES--L 10,000 1000 100 <br /> NOTES. * <br /> —If documented am <br /> umented soil and/or grwater contamination Is present, do not complete the leaching potential <br /> analysis. (i.e., site is currently on UCT Contamination list for soil or grand water.) <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. - <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> Levels for BTXSF are rot applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> STAFF RE ' . ATION/CCNCLUSION <br /> 1. Are 3TX ,C E or TPN Concentrations > Allowable Levels Yes1. o <br /> 2. Recommend Site Closun•e es o If Yes, Refer to Site Mitigatien for Evaluation <br /> . <br /> REVIEW -VALUATION • TO BE CCMPLETED BY A SUPERVISCR/SENICR <br /> CCNCR WITH STAFF RECCHME40ATICH FOR CLOSURE 14 ESI 0 I EFEARED TO SITE MITICATICH FOR EVALUATICH VES ( O <br /> pA1E RE FEARED / / ATE CLOSURE LETTER MAILED Cy j <br /> rrAME OF <br /> ':VALUATOR <br /> _N 23 30 (UG`-XSHT)\5/90 <br />