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SAN JOACUIH dkTY PUBLIC HEALTH SERVIC:S/ENVIRONMENTAL HEA^IVISICN p <br /> I, IST VORKSHET FOR SITE (SURE EVALUATION ATE I d /5 <br /> AME OF FACILITY I IRE= <br /> IB I � � <br /> i DRESS I _-TANK11)(faHK SIZEI L TYPE I tm <br /> II. GENERAL SITE HISTORY ` <br /> !s permit current? es >Vo ermit 0 I acility Status Code _Soil/GU Cont iYes o <br /> cumber of Tanks at facility lige of Tank(if available) l ype of Tank :cell <br /> rql ngl Dual <br /> i:i. TANK HISTORY <br /> Las tank tested? fes lyo ailed precision test ? f res If yes, give date(s) <br /> l as a repair made to the tank system? f res l No I f yes, what was repaired? <br /> yas repair done under inspection? fesI �JoI Jere soil samples analyzed? fres �to TXE I iTPH-G PH-0 l b/EDB <br /> Fype of failure/disch rge l tastrophicl (long-tens leakage Pverfill l ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SIE OFTAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples deceived �es l o, Depth to Ground Vater I rZef/Year) �verage Annual Precipitation <br /> Pei-Site Wells) lyes I �to I dumber L Type I Ilrr l Poa I puo f I <br /> S core Score S core <br /> iscance to Well(s) from Tank ft; - ft C 0 pts 9 pts C pts <br /> 0 f 0 it 0 f <br /> R onditicn A ct�dition R ondition <br /> 1:. Site Feature - Leaching Potential Analysis E s met E is met E rs met <br /> Minimum Depth to ground�rater from the Soil Sample (feet)3D-Ilf� � ( >100 l �1-100 I 125-50\1 <br /> :rac:ures in subsurface (applies to foothills or mountain areas) None I Unknown l resent <br /> Average Annual Precipitation (inches) =xxxx <10 1 9 110-25 poa000cx 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> bf leachate (i.e., septic systems, water wells, ponds) � � ( None ( Unknown ( resent <br /> Unique site features: Recharge area, =arse soil, or wells. At least ore than <br /> (Mu ncipal=>2000 ft; domestic->500 ft; irr/agricut tuural�resent; Nane one one <br /> COLUMN TOTALS»>TCTAL POINTS �D �'3- 13 <br /> 1 <br /> sample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or mare 41 - 48 pts 40 pts or5,ess <br /> �/'D Ar b - - <br /> +'3 MAXIMUM ALLOWABLE 3-T-X-E <br /> LEVELS (PPM) 6 SOI 50 SO I .3 i_3 I <br /> 1. 1. NA\3 <br /> amole Resul-: q LINE 1000 100 10 <br /> O P� .d. I I�Pm IMlM ALLDStA81� TPH L°VELS (PPM) <br /> IESEL 10,000 1000 100 <br /> 1�61 NO _/ —If documented soil and/or ground water contamination is present, do not complete the leachi <br /> P 3 G T, analysis. (i.e-, site is currently on UGT Contamination List for soil or ground water.) <br /> \ If depth is > 5 ft. and < 25 ft., stare Q points_ If depth <=5 ft., do not use table- <br /> \2 If precipitation is > 40 inches, scare 0 points. <br /> \3 Levels for 8TX&E are not applicable at a TPH cancentraticn of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENOATION/CONCLUSION <br /> 1. Are BTX S E or TPH Concentrations > Allowable Levels l Yes o <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> vII. REVIEW EVALUATION - TO BE CCKPLETED BY A SUPERVISOR/LEAD SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE �ES I �O l �E:cr2RED TO SITE MITIr.ATION FOR EVALUATION IES �0 l l <br /> r AT. RE-ZERRO l / / bAT'c CLOSURE LETTER MAILED / / <br /> i <br /> AME OF <br /> vALuarOR <br /> =H 23 80 (UGTWKSHT)\5/94 <br />