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SAN imairN CCUNTY PUBLIC HEALTH SERVICE-VENVIRONMENTAL HEALTH DIVISION <br /> US7 WORKSHEET FOR SITE wCSURE EVALUATION ATE7 4a <br /> _ <br /> AME OF FACILITY I S CORD ID ` 23 <br /> DRESS 4A ANK ID <br /> SANK SIZE pJEL TTtj�e e <br /> it. GENERAL SITE HISTORY <br /> I s ?erni c current? es o ermi t - pati L i ry Status Cade v x.Soi t/Gut Cont Yes (�to <br /> �txnber of Tanks at facility age of Tank(if available) Fype of Tank teed IFbrgl I5ngl Dual ) <br /> III. TANK HISTORY <br /> I:as Tank tested? es Iko ailed precision test ? fes IX �o ( f yes, give dates) <br /> �'as a repair made to the tank system? IYes I No f yes, what was repaired? <br /> ilas repair done under inspection? I I. �o ere sail samples analyzed?1Yes I �c I TXE I ' PH-G I �PH-D I b/EDB <br /> �iype of failure/discharge L tastrophicl long-term leakageMilt , ?her. <br /> IV. REMOVAL HISTORY (ATTACH INSPEr"f10N REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received fes o Pepth to Ground stater �ef/Year � average Annual Precipitation a= �14 h0-25 <br /> s-Size WeIL(s) �Yes I ro �tumber & Type Irr Pan pub <br /> S Score S core 5 care <br /> �iszarce to WeIL(s) from Tank ft; ft; ft C 10 pts C pts C pts <br /> 0 r 0 if 0 f <br /> R cnditicn R cndition R 'ition <br /> !!. Size Feature - Leaching Potential Analysis E is met E is met E ps met <br /> , <br /> ,Mini:;= Depth to grounckrater from the Soil Sample (feet)JO— ! =r I >100 I 1-100 I I _;-50\1 <br /> ;:rzc_ures in subsurface (applies zo foothills or mouitain areas) 1 None IUnknown present <br /> Average Annual Precipitation (inches) =xxxx ( <10 I 9 110-25 126-40\2 <br /> ,man-made conduits which increase vertical migration i <br /> cf Leacinate (i.e., septic systems, water wells, ponds) 1 D ( None Unknown resent <br /> lnicue site features: Recharge area, coarse sail, or wells. At least ore than <br /> i (M•..c <br /> ipal=>2000 ft; domestic->i00 ft; irr/agricut turat=present) Mane I I one one <br /> I COLUMN TOTALS»>TOTAL POINTS <br /> i <br /> Sample Result: (8 T X OR E) RANGE OF TOTAL POINTS 9 pts or more I 4.1 - Ca pts 40 pts or less <br /> 3!t-��1 pro n` _ <br /> 1,313- Ail ►V D AXAXIML14 ALLOWABLE B-T-X-E LEVELS (PPM) 16 50 50 50 .3 3 1. NA\3 <br /> II I � il - <br /> amole Result: LINE 1000 100 I 10 <br /> P, ^ <. ppm. IMM ALLOWABLE TPH LEVELS (PPM) <br /> 7 TPH <br /> r1r:SEL 10,000 I 1000 100 <br /> FOOTNOTES: —If documented sail and/or ground water contamination is present, do not complete the l ing potenti•at <br /> analysis. (i.e-, site is currently on UGT Contamination List for soil or ground wat W. <br /> 11 If depth is > 5 ft. and < 25 ft., score 0 points. If depth c5 ft., do not use table- <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> �3 Levels for STUE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> Vi. STAFF RECOMMENDATION/CCNCLUSION CS 7f_ J A 4- 3 b <br /> Are BTX & E or TPH Concentrations > Allowable Levels es o <br /> 12. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> .II. REVIEW EVALUATION - TO 8E COMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> _NCJR WITH STAFF RECOMMENDATION FOR CLOSURE �ES I �O EFz-RRED TO SITE MITIGATION FOR =VALUATION �ES ( �a I <br /> A�_ REFERRED I / / BATE CLOSURE LETTER MAILED <br /> , <br /> AME OF <br /> VALUATOR <br /> =H 23 80 (UGTWKSHT)\5/94 <br />