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SAN JOACUINATY PUBLIC HEALTH SERVICrS/ENVIRONMENTAL HEO"40IVISICN <br /> I. 1ST WCRKSHEET FOR SITE LCSURE EVALUATION ATE � <br /> AME OF FACILITY I .fQ ARD ID 1253 / <br /> OORESS ;�AANK ID 9 <br /> c I J <br /> ANK SiI L TYPE .7 <br /> II. GENERAL SITE HISTORY <br /> Is Permit current? es �Io ermit 4 - acitity Status Code oc.soil/GW cont es o <br /> i <br /> NLvber of Tanks at facility ge of Tank(if available) �ype of Tank teed rgl IS1191 I Dual <br /> ill. TANK HISTORY <br /> ILas Tank tested? fes o ailed precision test ? fes ! �o f yes, give dare(s) <br /> I:as a repair made to the tank system? es I No 1f yes, what was repaired? <br /> �.as repair done under inspection? les 1. �o Mere soil samples analyzed?IY s TXE + �PH-Gf PH-0 b/EDB <br /> �Iype of failure/discharge tastrophic long-tens leakage i ilLi they: <br /> W. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SI-1z DETAILS/COLLECT DATA FOR LEACHIN1G POTENTIAL ANALYSIS) <br /> poiL Samples Received Ices I o pepth to Ground Water IZef/Tear( Average Annual Precipitation �= I14 0-25 <br /> Site Wet l(s) (Yes I �Io I �umber & Type II rr I Pao I pub <br /> S core S core S core <br /> istance to WeLL(S) from Tank ft; ft; ft C 0 pts C pts C pts <br /> 0 t 0 if 0 f <br /> R ondition R ition R onditicn <br /> it. Site Feature - Leaching Potential Analysis E s met E is met = ps met <br /> Minimum Depth to groundwater from the Soil SamoLe Cfeet) 3 0I >100 �t-tp0 `� 25-50\1 <br /> Frac_ures in subsurface (applies to foothills or mountain areas) ( None IUnknown I present <br /> Average Annual Precipitation (inches) I '110 I 9 110-2s 26-40\2 <br /> Ian-Made conduits which increase vertical migration <br /> bf Leachate (i-e., septic systems, water wells, ponds) /� (None (Unknown ! resent <br /> � V I <br /> Unique site features: Recharge area, coarse soil, or wells. At Least �1ore than <br /> CMuncipal=>2000 ft; domestic=>500 ft; irr/agricultural=aresenrl None I or, <br /> I I one <br /> COLLMW TOTALS>»TOTAL POINTS / ! I <br /> tample Result: (8 T X OR E) RANG OF TOTAL POINTS 9 pts or more G1 - 48 pts I ptptenti-al <br /> IDS,;k <br /> D9I --All tJ D <br /> to —u I( N D fMAXI" ALLOWABLE 9-T-X-c LEVELS (PPM} 1 T Ix IE <br /> 50 50 50 I .3 �.3 t. + 1V I NA <br /> Pemote Result: LINE 1000 100 I <br /> SI I D IMUM ALLOWABLE TPH LEVELS (PPM) <br /> '�r a--�H IESEL 10,000 I 1000 1 <br /> COTNOTES: " If doccmented soil and/or ground water contamination is present, do not c=ptete the lea analysis. 0.e-, site is currently on UGT Contamination List for soil or ground water.) <br /> If depth is > 5 ft. and < 25 ft , scare 0 points_ If depth c5 ft_, donotusetable. <br /> l2 If precipitation is > 40 inches, score 0 points. <br /> �3 Levels for STX8E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (dies <br /> VT. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels es <br /> o v <br /> 2. Reconmend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> :I I- ,REVIEW EVALUATION - TO BE CCMPLETED 8Y A SUPERVISOR/LEAD SENIOR <br /> CNCUR WITH STAFF RECOMMENDATION FOR CLOSURE �ES� �0I EFERRED TO SITE MITIGATICN FOR =VALUATION �ES �O I <br /> P AT` REFERRED I / / bAh'c CLOSURE LETTER MAILED / / <br /> AME OF <br /> IALUATOR <br /> EH 23 80 (UGTWKSHT)\5/94 <br />