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. <br /> SAN ,IOAWI COCINTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HQ-.H DIVISION <br />` I UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE � 0 <br /> f AIDE OF FACILITY .I it �ECm ID <br /> ODRESS / I - <br /> !i MANX 10 A-I <br /> ANK SIZE I Ek&6V�( L TYPE <br /> II. Gc'?I'cRAL SITE H15TCRT <br /> Is permit current? es �Ea ermit v - aciEiry Status Code Poe.SoiL/GLI Cant es I o <br /> i <br /> Number of Tanks at facility f �lge of Tank(if available) Fype of Tank t.E rgE ngE Duan <br /> III. TANK HISTORY ° I <br /> it <br /> i <br /> as Tank tested? esIo ailed precision test 7 yes of If yes, give date(s) <br /> as a repair made to the tank system? es No tyes, what was repaired? i <br /> 'as repair done under inspection? les 10 dere soil samoles analyzed? IYes P}I-G PH-0 �b/ED$ <br /> type of failure/dischargeI tastraphic � fang-term leakage �verfiI then: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION-REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soi I Samoles Received �es o �epth to Ground Water,,' ef/Year l ; average Arr-mmi Precipitation = X94 �0-?5 <br /> Sr.-Site We L L(s) 1Y es �o I �Umcer & Type li rr I �j pcm I �I t <br /> i1} S Score 5 cars S core <br /> is:ance to WeLL(s) from Tank I ft; ft; ! ft C 10 pts C pts C pts <br /> 0 if O i. O f <br /> R ondition R andition R onditian <br /> Il. Site Feature - Leaching Porentiat Amiysis c' is met Eis met C his met <br /> Niniraan Depth to grouncuater from the SoiL Sample Cfeet) >100 I 1-100 25-=0u <br /> rr•actures in subsurface (applies to foothills or mountain:areas) I None Unmown resent <br /> Overage Annual Precipitation (inches) _ ( <10 9 10-25 � 25-40N2 <br /> ��� an-Made conduits which increase vertical migration <br /> f leacnate (i.e., septic systems, water wells, Ponds) j' None I Unknown resent <br /> Lnicue site features: ,Recharge area, coarse soil, or we{is. � � � � At Leastf are hon <br /> IMv c:caL=>2000 ft; domestic=-500 ft; irr/agricutrurai=p esentl None oneI ane <br /> �1 <br /> COLUMN TOTALS}>?TOTAL POINTS <br /> ;; 'zo <br /> Sample Res ut _ (B T X OR c) RANGE OF:TOTAL POINTS 9 pts or more 41 - -8 pts pts or Less <br /> f ,�y a T Ill <br /> 110 <br /> X "cFtAXII�MI ALLOIJABLE B-T.X-sj,LeVELS (PAM) 1 150 50 5 .3 J.3 1. 1. NA\3 <br /> ample R s�� IrtA4 ALLOCIABL= TPM LL~VELS (PAM7 LINE 1000 f 100 i0 <br /> TPH i� fESEL 10,1100 I 1000 100 <br /> C TNOTES_ '" if documented soil and/or ground water contamination is present, do not complete the Leaching ,oatenriat <br /> anaLysis. 0.e-, site is currently on U(;T Contamination List for soil or ground water.) <br /> \1 If depth is > 5 ft. and < 25 ft., scare 0 points.'if depth <=5 ft., do not use table. <br /> �2 If precipitation is > 40 inches, score'0 points- <br /> Levels for 3TX&E are nor appEicabEe at' a TPH concenrrarion of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RE£dMMENOATION/CONCLUSION <br /> ,�. 4(C <br /> I. Are "BTX & or TPH Concentrations > ALLoxable Levels l es o r <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> ONCUR uEFERRED TO SITE MITIGATION FOR EVALUATION p S � �o <br /> AT_5--RE-irc>IR�] ATE CLO <br /> s <br /> AME OF <br /> VALUATCR <br /> EH 23 80 (U 1KSHT)\5/9 <br />