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SAN "MINIL ATY <br /> PUBLICHEALTH <br /> LLTH SITEICES/0 ENVIROHMENTILNE4 DIVISION TE tt <br /> 1. 1' <br /> Of FACILITY n J EPS C0� <br /> SS '10 _ j — <br /> ANK 10 N <br /> RAWSt2E �UEL TYPE GaC -6 i?Se'f Q YIGL�1� <br /> It. GENERAL SITE HISTORY ri <br /> s perait current7tsormit 9 - scility Status Code oc.Soil/GW Cant as <br /> of Tanks at ge of Tanks(if available) ypt of Tank test brgl t Cwt <br /> 111. TANK HISTORY <br /> Tank tested? ss ailed precision test 7 as 70 f yes, give date(:) <br /> a repair made to the tank system? Yes No f yea, what was repaired? <br /> s repair done under inspection? es 40 e soft samples anstred? *s TXE PN-G PN•D ECO <br /> of failura/discharge tsstrophietong-tons leakage fit? I kmown I lother: <br /> IV. REMOVAL HISTORY (ATTACK INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> it Samples Received es th to Ground Water of/Yew verag* Annual Precipitation s i 0-25 <br /> Site Watt(s) es 100 �umber i Type I vilrr9 <br /> S cart S * S ore <br /> istance to Wits) from Tank ft; ft; ft C 0 pts C 9 pts C pts <br /> 0 f 0 if 0 f <br /> R ondition R onditIan R ondition <br /> Sit* feature - Leaching Potential Analysis E s not E is met E s met <br /> ininA Depth to groundwater from the Soil Sampte (foot) /0 -100 1-100 2S-50.0 <br /> ractures in subsurface (applies to foothills or mountain areas) Hare unknown resent <br /> verage Annual Precipitation (inches) <10 9 10.25 26-40.0 <br /> -Made conduits which increase vertical migration <br /> f t*achst* (i.e., septic systems, water walls, ponds) ` None Unknown resent- <br /> 4A sit* features: Recharge area, coarse soil, nearby wells. Q At Least fare than <br /> rxxxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS ♦ q7 ♦ O <br /> * Result: (R T X OR E) RANGE OF TOTAL POINTS9 pts or more • 43 pts 40 pts or less <br /> 'T-= •�L+}I <br /> BIT Ix E 8 T JXJE <br /> Jr •ofMAXIMUM ALLMMU H-T•X•E LEVELS (PPM) I SO SO SO .3 3 11. <br /> ;awt* Result: INE 1000 100 10 <br /> A� TON 1MUM ALLWSLE TPN LEVELS (PPM) IESEL 10,000 1000 100 <br /> OOTNOTES: i —If meted soil ardor ground wat*r contamination is present, do not complete the teaching potential <br /> analysis. (i.*., site is currently on UGT Contamination List for soil or ground water.) <br /> If depth is > S ft. and < 25 ft., score 0 points. If depth 44 ft., do not use table. <br /> If precipitation is > 40 inches, score 0 points. <br /> Levels for STX&E are not appticabts at a TPH concentration of 10 ppm (gasoline) or 100 <br /> Ops (diesel). <br /> Vt. STAFF RECOMMEIDATIOM/CONCLUSION ,. <br /> I. Are RTX i E or TPN Concentrations > Attowmble levels Yes o ' <br /> 2. Recommend Site Closurt es If Yes, Refer to Sit* Mitigation for Evaluation <br /> VII. REVIEW EVALUATION • TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> E <br /> ITN STAFF REMWEMDATION FOR CLOSURE ES FERREO TO SITE MITIGATION felt EVALUATION ESERRED / / TE CLOSURE LETTER MAILEDR P/T <br /> EH 23 30 (IJGTVKSNT)45/90 �P/k cSC t 4a e— nF/necllcL <br />